Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Loma Linda Post Acute during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions in the kitchen, including dish drying racks with black substance build-up, cracks, and corrosion, as well as scoops with dry food residue stored among clean utensils. Additionally, expired wheat tortillas were found in the refrigerator, and facility policies regarding sanitation and food storage were not followed, as confirmed by the kitchen director.
A resident was admitted with major depressive disorder, anxiety disorder, and PTSD, but the PASARR assessment did not reflect these mental health diagnoses and incorrectly indicated no serious mental illness. The MDS nurse, responsible for reviewing PASARR accuracy, acknowledged the oversight, and the facility did not identify or correct the discrepancy as required by policy.
A resident with a history of mental health conditions was newly diagnosed with Paranoid Schizophrenia, but the facility did not notify the State Mental Health or Intellectual Disability authorities or complete a required PASARR. Staff interviews confirmed that the MDS Coordinator was responsible for these actions, but they were not carried out, and facility policy was not followed.
A resident with complex medical needs did not receive the physician-ordered frequency of physical therapy sessions, missing one session in a week without any documentation or explanation in the clinical record. Facility staff failed to follow policy requiring documentation of missed or refused treatments.
A resident with chronic kidney disease and dependent on dialysis was not consistently provided with a sack lunch to take to dialysis appointments, as required by physician orders and facility policy. Facility records and interviews confirmed multiple missed meals, and the DON acknowledged that an order for sack lunches was never obtained at admission. The resident experienced notable weight loss during this period.
A resident who required pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
Staff did not assess or document the condition of a resident's dialysis access site or general condition after the resident returned from scheduled hemodialysis treatments, despite care plan and policy requirements. The required Hemodialysis Communication Observation/Assessment forms were left incomplete on two occasions, and the DON confirmed that these assessments should have been performed and documented.
Three expired over-the-counter medications—Simethicone, Vitamin A, and Vitamin B complex—were found stored in a medication cabinet. Both the RNS and DON confirmed these medications should have been discarded per facility policy, but the expired drugs remained accessible in the medication storage room.
The facility did not post its most recent recertification survey results, leaving residents and visitors unable to access this information. A binder intended to contain survey results for multiple years was missing the latest report, and the Administrator confirmed the results were not available elsewhere in the facility, contrary to facility policy requiring survey reports to be readily accessible.
A resident with multiple medical conditions and a high fall risk assessment experienced an unwitnessed fall after being left in a room located in a busy hallway rather than near the nurse station. Despite care plan directives and facility policies requiring targeted interventions for fall prevention, the supervision and measures provided were insufficient, resulting in the resident being found on the floor and sent to the hospital for evaluation.
A facility failed to complete and transmit a discharge MDS for a resident, as required by CMS guidelines. The resident was readmitted and later discharged, but the discharge MDS was not completed within the required timeframe. Interviews with the MDS Coordinator, DON, and Administrator confirmed the oversight and highlighted the expectation for timely and accurate MDS assessments.
A resident with a complex medical history was found unresponsive with an unprescribed bottle of pills at their bedside, leading to a suspected narcotic overdose. The facility failed to report the incident to the state agency within the required 24-hour timeframe, as confirmed by the DON. The resident was later diagnosed with cardiac arrest and opioid overdose at an acute hospital.
Unsanitary Kitchen Conditions and Expired Food Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several observations during inspection. Dish drying racks used for air-drying sanitized dishes were found to have significant black-colored substance build-up, scratches, cracks, and corrosion on both the interior and exterior surfaces, as well as on supporting pillars. The Director of Kitchen confirmed these unsanitary conditions and acknowledged the risk of cross-contamination, noting delays in receiving replacement racks. Additionally, three scoops with dry food residue were discovered stored among other clean scoops in a drawer designated for clean utensils. The Director of Kitchen was unable to explain how these unsanitary scoops were placed with clean ones. Further inspection revealed four bags of wheat tortillas in the walk-in refrigerator that were past their expiration date, which the Director of Kitchen confirmed should have been discarded. Review of facility policies and procedures indicated that the Food and Nutrition Services Director is responsible for ensuring sanitation and that no food should be kept beyond its expiration date. The Director of Kitchen acknowledged that these policies were not followed. Reference to the FDA Federal Food Code highlighted the requirement for non-food-contact surfaces to be free of food residue and other debris.
Failure to Accurately Update PASARR Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASARR) assessment for a resident who was admitted with diagnoses of major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Upon review, it was found that the PASARR assessment used for admission did not include the resident's diagnoses of major depressive disorder and anxiety disorder, and incorrectly indicated that the resident did not have a serious mental illness. The resident's medical records showed ongoing treatment with buspirone for anxiety and fluoxetine for depression, and these conditions were documented in the admission and social history records. Interviews with facility staff revealed that the Minimum Data Set (MDS) nurse was responsible for reviewing the completion and accuracy of PASARR assessments for all new admissions. The MDS nurse acknowledged that the PASARR assessment was inaccurate and should have been revised to reflect the resident's mental health diagnoses, but this was not done. The facility's policy required all new admissions to be screened for mental disorders per the PASARR process, but the discrepancy in the resident's assessment was not identified or corrected.
Failure to Notify State Authorities and Complete PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to notify the State Mental Health authority or the State Intellectual Disability authority when a resident was newly diagnosed with Paranoid Schizophrenia. The resident, who had a history of bipolar disorder, unspecified dementia with behavioral disturbance, and post-traumatic stress disorder, was diagnosed with Paranoid Schizophrenia and Schizophreniform Disorder on December 3, 2024. A review of the clinical record showed there was no documentation that a Preadmission Screening and Resident Review (PASARR) was completed following the new diagnosis, nor was there evidence that the California Department of Health Services or the State Mental Health Department were notified as required. Interviews with facility staff, including the DON and the MDS Coordinator, confirmed that the responsibility for making such notifications and referrals lies with the MDS Coordinator. The MDS Coordinator acknowledged the requirement to notify the appropriate state authorities and complete a new PASARR when a resident is identified with a new mental disorder diagnosis or experiences a significant change in status. However, the MDS Coordinator could not explain why these actions were not taken for this resident. Review of the facility's policy and procedure confirmed the requirement for prompt notification and PASARR completion, which was not followed in this instance.
Failure to Provide Ordered Physical Therapy and Document Missed Sessions
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including end stage renal disease, encephalopathy, respiratory failure, wounds, and legal blindness, did not receive physical therapy services as ordered by the physician. The resident was supposed to receive physical therapy four times a week for four weeks, as documented in the care plan and physician's orders. However, during the week in question, the resident only received three physical therapy sessions instead of the prescribed four. There was no documentation in the clinical record explaining the missed session or the reason for the deviation from the physician's order. Interviews and record reviews confirmed that facility staff did not document the missed physical therapy visit or provide a reason for the absence, despite facility policy requiring such documentation. The lack of adherence to the prescribed therapy schedule and the absence of required documentation were confirmed by the Regional Rehab Resource during a review of the resident's clinical record. Facility policies and best practices reviewed also indicated that all missed or refused treatments should be documented, which was not done in this case.
Failure to Provide Required Sack Lunches for Dialysis Resident
Penalty
Summary
Staff failed to provide required nutritional services to a resident dependent on dialysis, as the resident was not consistently given a sack lunch to take to dialysis appointments on multiple occasions. The resident, who had chronic kidney disease, anemia, and sepsis, reported not receiving a sack lunch on several dialysis days and sometimes missing breakfast as well. Review of the facility's records confirmed that on several documented dates, the resident was not provided a sack meal for dialysis, despite physician orders specifying a renal diet and nutritional supplements. The facility's policy required notification of dietary staff for sack lunches on dialysis days and monitoring of special diets, but this was not followed. The DON acknowledged that a physician's order for a sack lunch should have been obtained at admission but was not. The resident experienced a 5.17% weight loss over a three-month period, as documented in the clinical record, during the time when sack lunches were not consistently provided.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this failure, nor does it include information about the resident's medical history or condition at the time.
Failure to Assess and Document Dialysis Access Site Post-Treatment
Penalty
Summary
Facility staff failed to provide required assessment and monitoring for a resident who was dependent on hemodialysis. The resident, admitted with chronic kidney disease, dependence on renal dialysis, anemia in chronic kidney disease, and sepsis, had physician orders for dialysis three times weekly at an outside facility. The resident's care plan specified that staff should monitor, document, and report any signs or symptoms of infection or complications at the dialysis access site, including redness, swelling, warmth, drainage, bleeding, or hemorrhage. However, on two separate occasions following the resident's return from dialysis, there was no documented evidence that staff assessed the dialysis access site or the resident's general condition, as required by both the care plan and facility policy. Review of the Hemodialysis Communication Observation/Assessment forms for the relevant dates showed that sections for access site assessment, general condition, and pain level were left blank. The DON confirmed that staff were expected to assess and document the resident's status and access site immediately upon return from dialysis, but this was not done. Facility policy also required such assessments to be completed and documented. The lack of assessment and documentation was confirmed through record review and staff interview.
Expired Medications Found in Storage
Penalty
Summary
During an inspection of the medication storage room, three over-the-counter bottles of medication—Simethicone, Vitamin A, and Vitamin B complex—were found stored past their expiration dates. The Simethicone had expired in January 2025, the Vitamin A in June 2024, and the Vitamin B complex in September 2024. These expired medications were discovered in a medication cabinet accessible within the facility. Interviews with the Registered Nurse Supervisor (RNS) and the Director of Nurses (DON) confirmed that the expired medications should have been discarded according to the facility's policies and procedures. The facility's policies, reviewed during the survey, clearly state that expired medications must be removed from active supply and destroyed, and that discontinued, expired, or deteriorated drugs and biologicals are not to be used. Both the RNS and DON acknowledged that these policies were not followed, resulting in the continued storage of expired medications.
Failure to Post Most Recent Survey Results
Penalty
Summary
The facility failed to post the results of its most recent recertification survey, as required, resulting in residents and visitors being unable to view the survey results and assess the facility's compliance with regulations. During an observation, a binder labeled as containing survey results for 2022, 2023, and 2024 was found posted in a main hallway, but upon review, it did not contain the 2024 recertification survey results. The Administrator confirmed that the most recent survey results were supposed to be in the binder but were missing, and also stated that the survey results were not posted anywhere else in the facility. The facility's policy indicated that survey reports and plans of correction should be readily accessible to residents, family members, resident representatives, and the public, and that a copy of the most recent survey report and any plans of correction should be kept in a binder in the residents' day room.
Failure to Provide Adequate Supervision for High-Risk Fall Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent avoidable accidents for a resident who was identified as high risk for falls. The resident, who had multiple diagnoses including pulmonary edema, abnormalities of gait and mobility, hypertension, respiratory failure, and colon cancer, was assessed as a high fall risk upon admission. The care plan indicated the resident was at risk for falls due to altered balance, unsteady gait, and confusion, and required assistance with activities of daily living. Despite these identified risks, the resident experienced an unwitnessed fall during the night, after being last repositioned by a CNA and later found on the floor calling for help. The facility's fall risk management policies required staff to identify and implement interventions based on the resident's specific risks and causes for falling. However, the resident was not placed near the nurse station and was located in a busy hallway instead. The bed was in the lowest position, and staff reminded the resident to use the call light, but the resident was not ambulatory and required assistance. The fall resulted in the resident being sent to an acute hospital for evaluation. Documentation and interviews confirmed that the interventions in place were insufficient to prevent the fall, despite the resident's high-risk status and care plan directives.
Failure to Complete and Transmit Discharge MDS
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) for a resident, as required by the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The facility's policy, revised in March 2022, mandates that a comprehensive assessment of every resident's needs be conducted at intervals designated by OBRA and PPS requirements, including a discharge assessment. However, the discharge MDS for the resident, who was readmitted on September 10, 2022, and discharged on March 13, 2024, was not completed. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator revealed that the discharge MDS was overlooked. The MDS Coordinator acknowledged the oversight and stated that she had 14 days to complete and submit the discharge MDS after a resident's discharge. The DON confirmed that the discharge MDS was missed and emphasized the expectation for MDS assessments to be completed accurately and submitted timely. The Administrator also expressed the expectation for timely and accurate completion and submission of MDS assessments.
Failure to Timely Report Narcotic Overdose Incident
Penalty
Summary
The facility failed to report a possible overdose of narcotics for a resident within the required 24-hour timeframe to the state agency, as per their policy. The resident, who had a complex medical history including chronic respiratory failure, end-stage renal disease, and type 2 diabetes, was found unresponsive with shallow breathing and low oxygen levels. An unprescribed and unlabeled bottle of pills was discovered on the resident's bedside table, leading to the suspicion of a narcotic overdose. The resident was sent to an acute hospital where they were diagnosed with cardiac arrest and opioid overdose. The Director of Nursing (DON) acknowledged that the incident, which occurred on a specific date, was not reported to the California Department of Public Health (CDPH) until several days later, following a verbal report from a hospital social worker about the resident's death due to overdose. The facility's policy required unusual occurrences to be reported via telephone within 24 hours and a written report within 48 hours. The delay in reporting was confirmed by the DON, who stated that they were waiting for updates from the hospital and family before making the report.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Loma Linda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Gardens Health Care Center | 0.3 mi | ★★★★★ | 18 | 0 |
| Asistencia Villa Healthcare Center | 1.2 mi | ★★★★★ | 18 | 0 |
| Totally Kids Rehabilitation Hospital - D/p Snf | 1.4 mi | ★★★★★ | 10 | 0 |
| The Canyons Post-acute | 2.4 mi | ★★★★★ | 8 | 0 |
| Brookside Healthcare Center | 2.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.