Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Totally Kids Rehabilitation Hospital - D/p Snf during CMS and state inspections, most recent first.
Arbitration Agreements Lacked Venue Selection Language: The facility failed to ensure arbitration agreements for three residents included a venue selection convenient to both parties. Record review showed the residents had significant medical conditions, and the DCM confirmed the agreements did not contain the required venue information. The ADMIN stated the form did not provide for venue selection and the facility had no P&P for arbitration agreements.
Late Comprehensive MDS Assessment: The facility failed to complete and submit a comprehensive MDS within the required 14-day timeframe for a resident admitted with arthrogryposis and multiple congenital anomalies. The MDSC and CNO both acknowledged the assessment was completed 21 days late, despite the facility policy requiring comprehensive assessments within 14 calendar days of admission.
Late Quarterly MDS Assessment: The facility failed to complete a resident’s quarterly RAI/MDS within the required 92-day timeframe. The MDSC and CNO stated the last quarterly assessment was completed 100 days after the prior one, and the next quarterly assessment due was still not completed when reviewed. The resident had diagnoses including arthrogryposis and multiple congenital anomalies, and the facility policy required quarterly reviews at least every 92 days.
MDS Section I active diagnoses were inaccurately coded for four residents. One resident’s quarterly MDS incorrectly checked viral hepatitis and left seizure disorder blank despite a seizure dx, while another resident’s annual MDS left neurogenic bladder blank despite a bladder problem. Two other residents’ annual or quarterly MDSs left seizure disorder blank even though their records showed seizures. The MDSC, CM, and CNO verified the coding errors and stated the assessments were incorrectly completed.
A resident with cerebral palsy and chronic respiratory failure was hospitalized for new-onset seizures and later had recurrent tonic seizures documented by Neurology. The resident was prescribed Keppra and clonazepam for seizure management, but the LTCP did not reflect the seizure diagnosis until much later. The CM stated the seizure care plan should have been started when the resident returned from the hospital, and the CNO stated a new diagnosis like seizures requires an immediate individualized care plan.
A facility failed to follow its P&P for weekly replacement of suction canisters and suction tubing for two trach/vent-dependent residents. One resident’s suction setup was 13 days old with light green fluid, and another’s was 9 days old with cloudy green fluid, brown foam, and sediment. RT confirmed the equipment should be changed at least weekly, and the CNO stated staff were expected to follow the weekly replacement policy.
Hand Hygiene Not Performed During Wound Care: An LVN did not follow infection control practices during wound care for a resident with a right neck wound, quadriplegia, and cerebral palsy. After removing the old dressing and cleansing the wound, the LVN applied skin prep, collagen, calcium alginate, and a new dressing without performing hand hygiene or changing gloves, despite facility training and policy requiring hand hygiene after contact with wound dressings.
A resident with complex medical needs was subjected to verbal abuse by a CNA, who used foul and intimidating language in the presence of a nursing student. Prior concerns about the CNA's conduct had been raised by staff and a family member, and facility records showed previous disciplinary action for unprofessional behavior. The incident violated the facility's abuse prevention policy, as confirmed by the CNO.
The facility failed to complete and submit MDS assessments for nine residents within the required timeframes, resulting in inadequate monitoring and lack of information for CMS. The DCM cited staffing issues as the reason for delays, with some assessments being overdue by up to 157 days.
The facility failed to review the Monthly Medication Review (MRR) recommendations from the pharmacist in a timely manner for two residents. The pharmacist sent the MRR to the CNO, but the facility lacked a policy with specific timelines for review, resulting in a two-month delay in physician response. The CNO acknowledged the delay, which contradicted the facility's goal of a one-week review period.
A facility failed to implement Enhanced Barrier Precautions during wound care for a resident, as staff did not wear gowns, contrary to CMS guidance. Additionally, a nurse did not follow sterile technique during urinary catheterization for a resident with neurogenic bladder, using non-sterile gloves and compromising the sterile field. The nurse also failed to perform hand hygiene after resident contact, breaching infection control policies and CDC guidelines.
A facility failed to maintain a comprehensive care plan for a resident with a tracheostomy and ventilator-dependent status. Despite physician's orders for respiratory care, the care plan was mistakenly closed, leaving the resident without an active plan for his respiratory needs. Interviews with facility staff confirmed the oversight, which was contrary to the facility's policy requiring individualized care plans.
The facility failed to ensure the proper verification process for controlled medications was completed accurately for two medication carts. Observations and interviews revealed missing signatures on Controlled Substance Inventory Count forms for Valtoco Nasal Spray, indicating that the required verification process was not followed. The facility's policy mandates that both the nurse leaving the shift and the nurse coming on duty must verify and document the count of controlled substances, which was not adhered to, potentially leading to the diversion of medications.
A resident with complex medical needs was prescribed lorazepam for agitation with a PRN order exceeding the 14-day limit without documented rationale. The medication was administered multiple times over 20 days. Interviews revealed a lack of policy and reliance on the pharmacist for compliance, leading to a deficiency in medication management.
An expired bottle of Humulin R was found in an E-Kit during an observation in the medication storage room. The Charge Nurse confirmed the expiration, and the facility's policy for medication management was not followed. The in-house Director of Pharmacy stated that nurses should ensure medications are not expired and notify the pharmacy for replacements.
The facility failed to follow safe food storage practices, with expired onions and unlabeled ice cream found in storage areas. A staff member acknowledged the oversight, and the Registered Dietician confirmed the need for proper labeling. These lapses could risk foodborne illness to residents.
Arbitration Agreements Lacked Venue Selection Language
Penalty
Summary
The facility failed to ensure that arbitration agreements provided a selection of a venue convenient to both the facility and the resident for three sampled residents. During interview and record review, Resident 27’s admission record and H&P showed admission with diagnoses including chronic respiratory failure, deletion of chromosome 1p36, and Tetralogy of Fallot; Resident 47’s H&P showed admission with diagnoses including chronic lung disease, recurrent pneumonias, and gross developmental delay; and Resident 51’s admission record and H&P showed admission with diagnoses including chronic respiratory failure, cerebral palsy, and spastic quadriplegia. During a concurrent interview and record review with the Director of Case Management, the arbitration agreements for Residents 27, 47, and 51 were reviewed and each was found not to include information regarding the selection of a venue convenient to both parties. The Director of Case Management confirmed that the binding arbitration agreements for all three residents did not have this information and stated there should have been. During a later interview, the Administrator stated the arbitration agreement form did not provide for the selection of a venue convenient to both parties and that the facility did not have a policy and procedure for arbitration agreements.
Late Comprehensive MDS Assessment
Penalty
Summary
The facility failed to ensure a comprehensive MDS assessment was completed and submitted to CMS within the required federal timeframe for one sampled resident. Resident 23 was admitted with diagnoses including arthrogryposis and multiple congenital anomalies. The MDS Coordinator Nurse stated that comprehensive assessments are expected to be completed within 14 calendar days of admission, and the Chief Nursing Officer gave the same expectation during interview. Record review showed Resident 23’s comprehensive/admission MDS assessment for May 2025 was due on April 28, 2025, but was not completed until May 19, 2025, which was 21 days late. During interview and record review, the MDS Coordinator Nurse and the Chief Nursing Officer both acknowledged the assessment was late. The facility policy titled Minimum Data Set (MDS) Assessments, dated March 2024, stated comprehensive assessments must be completed within 14 calendar days after admission, on significant change in status, and annually.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that Resident 23’s quarterly RAI/MDS assessment was completed within the required 92-day timeframe following the prior assessment. Resident 23’s history and physical dated April 14, 2024, documented admission to the facility with diagnoses including arthrogryposis and multiple congenital anomalies. During interview and record review, the MDS Coordinator Nurse stated that quarterly assessments are her responsibility and that they are expected to be completed within 92 days of the prior quarterly assessment. During the review, the MDS Coordinator Nurse and the Chief Nursing Officer both stated that Resident 23’s last quarterly assessment was completed on January 5, 2026, which was 100 days from the previous assessment, and that the quarterly assessment due on April 7, 2026 had not been completed and was 8 days late. Review of the facility’s policy titled Minimum Data Set (MDS) Assessments, dated March 2024, showed that quarterly review assessments must be completed at least 92 days following the previous assessment of any type. The CNO stated that the policy was not followed.
MDS Section I Active Diagnoses Were Inaccurately Coded
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect residents’ active diagnoses in Section I for four residents. During review of Resident 1’s admission record and H&P, the resident was noted to have traumatic brain injury, left foot fracture, and right big toe fracture. On review of the resident’s quarterly MDS, Section I incorrectly had viral hepatitis checked, and the seizure disorder item was left blank even though the resident had a seizure disorder. The Case Manager Nurse stated the viral hepatitis entry was checked by mistake and verified that the seizure disorder was not documented correctly. Resident 19’s admission record and H&P showed diagnoses including anoxic brain injury, spastic quadriplegia, and ventilator dependence. On review of the resident’s annual MDS, Section I for active diagnoses, the neurogenic bladder item was left blank, indicating no bladder issue was coded. The MDS coordinator verified that the MDS was coded incorrectly and stated the resident had a bladder problem. Resident 20’s admission record and H&P identified diagnoses including premature infant, chronic lung disease, and seizure. On review of the resident’s annual MDS, Section I for active diagnoses, seizure disorder or epilepsy was left blank. The Director of Case Management verified that the seizure was not documented correctly because the resident had seizures. Resident 23’s H&P listed arthrogryposis, chronic lung disease with tracheostomy, and focal seizures. On review of the resident’s quarterly MDS, Section I for seizure disorder or epilepsy was left blank. The Case Manager stated the MDS coordinator did not accurately complete the assessment and that active diagnoses should not have been left blank. The facility’s policy required accurate and complete MDS data to be transmitted within 14 days, and the Chief Nursing Officer stated the policy was not followed and the quarterly MDS was incorrectly coded.
Failure to Develop Seizure Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 46 after the resident was diagnosed with new-onset seizures and prescribed seizure medications. Resident 46 had been admitted with diagnoses including cerebral palsy and chronic respiratory failure. A discharge summary dated January 15, 2026, documented hospitalization for new-onset seizure, and a neurology consult dated January 22, 2026, documented recurrent tonic seizures. An LTC physician order review dated April 15, 2026, showed orders for Keppra 750 mg twice daily and clonazepam 0.25 mg once daily for seizure management. During interview and record review on April 16, 2026, the resident’s LTCP was reviewed and showed the seizure care plan was initiated that day. The case manager stated the seizure LTCP should have been put into place when the resident returned from the hospital on January 15, 2026, but there was no documented evidence of a seizure care plan in the electronic chart. The case manager also stated the LTCP should be individualized and communicate specific resident needs to ensure consistent observation and care between staff. The CNO stated that when a patient has a new diagnosis such as new-onset seizures, staff are expected to initiate a care plan related to the diagnosis and new medication immediately.
Expired suction equipment left in use for tracheostomy patients
Penalty
Summary
The facility failed to provide respiratory and tracheostomy care consistent with its policy and procedure for two sampled patients, Patient 14 and Patient 46, when suction canisters and suction tubing were not changed weekly and remained available for continued use. Patient 14 was admitted with acardi syndrome and respiratory failure with tracheostomy and ventilator dependence. During observation, Patient 14’s suction canister and tubing were dated 13 days from the last change and contained 500 ml of light greenish liquid. The respiratory therapist confirmed the dates and stated the canister should be changed at least every seven days, and more often if dirty or gunky. Patient 46 was admitted with cerebral palsy and chronic respiratory failure with tracheostomy and ventilator dependence. During observation, Patient 46’s suction canister and tubing were dated 9 days from the last change and contained 750 ml of cloudy green liquid with brownish foam and sediment in the canister. The respiratory therapist confirmed the dates and stated the canister and tubing should be changed at least every 7 days, and more often if soiled or full. The chief nursing officer reviewed the facility’s disposable equipment policy, which required suction tubing and suction canisters to be replaced weekly, and stated staff were expected to follow that policy.
Hand Hygiene Not Performed During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when an LVN did not follow safe infection control practices during wound care for one resident with a right neck wound. The resident had diagnoses including quadriplegia, cerebral palsy, and an erosive right neck wound. MD orders dated March 2, 2026 directed daily wound care to cleanse the right neck wound with normal saline, pat dry, apply skin prep, collagen sheet, calcium alginate, and cover with a Mepilex dressing. During observation in the resident’s room, the LVN performed hand hygiene, put on sterile gloves, removed the old dressing, cleansed the wound with sterile normal saline and gauze, and patted the wound dry. The LVN then applied skin prep and placed the collagen, calcium alginate sheet, and new dry dressing without performing hand hygiene and without changing gloves. In interview, the LVN acknowledged she did not change her gloves after removing the old dressing and before cleansing the wound and applying the new dressing. The facility’s dressing change training stated to remove the soiled dressing, perform hand hygiene again, don sterile gloves, clean the wound as ordered, and apply the dressing as ordered. The facility’s hand hygiene policy stated to decontaminate hands after contact with wound dressings if hands are not visibly soiled, and the CNO stated the policy was not followed.
Verbal Abuse of Resident by CNA
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) verbally abused a resident, as witnessed by a nursing student. The CNA used foul and intimidating language, telling the resident to "get back in that damn bed" and later repeating the command with profanity. The incident was corroborated by a nursing student's written statement and was reported to facility management. The resident involved had a history of extreme prematurity, short gut syndrome, and was dependent on a gastrostomy tube for nutrition and medication. Interviews with other staff and a resident's family member indicated prior concerns about the CNA's behavior, including rough handling and negative interactions with staff and residents. Review of facility records showed that the CNA had previously received a disciplinary action for unprofessional interactions and had signed an acknowledgment of the facility's abuse prevention policy, which defined verbal abuse and required staff to maintain respectful conduct. Despite these measures, the CNA's actions violated the facility's policy and the resident's right to be free from abuse. The Chief Nursing Officer confirmed that the policy was not followed in this instance.
Failure to Timely Complete and Submit MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for nine residents were conducted and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required federal submission timeframes. The Director of Case Management (DCM) acknowledged that the MDS assessments were supposed to be completed quarterly, approximately every 90 days. However, due to staffing issues, multiple residents had their assessments completed late, with some assessments being delayed by up to 157 days. This resulted in inadequate monitoring of the residents' progress or decline and a lack of resident-specific information being sent to CMS for payment and quality measure monitoring. The facility's policy and procedure for MDS assessments, revised in March 2024, required comprehensive assessments to be completed within 14 days after patient admission, on significant change in status, and annually. Additionally, quarterly review assessments were to be completed at least every 92 days following the previous assessment. Despite these guidelines, the facility did not adhere to the required timeframes, as evidenced by the late completion of MDS assessments for the nine residents reviewed. The DCM attributed the delays to being the sole individual responsible for entering the assessments, which typically involved more personnel.
Delayed Review of Monthly Medication Recommendations
Penalty
Summary
The facility failed to ensure that the Monthly Medication Review (MRR) conducted by the pharmacist was reviewed in a timely manner for two residents. The pharmacist completed the MRR and sent the recommendations to the Chief Nursing Officer (CNO) at the beginning of each month. However, the facility did not have a policy and procedure in place that included timelines and steps to be followed once the MRR was received. This resulted in a delay of two months in the physician's review of the MRR recommendations, which included medications for antipsychotics and hypnotics. The CNO acknowledged the delay and stated that the goal for review is one week. The facility's policy did not outline the expectations related to the MRR and physician review or specify time frames for the process. The CNO had delegated a nurse to review the MRR with the physicians, but the delay persisted. The policy indicated that urgent concerns should be brought to the CNO's attention immediately, but this was not effectively implemented, leading to potential risks for the residents involved.
Infection Control Deficiencies in Wound Care and Catheterization
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident with erosive wounds caused by tracheostomy dressing changes. During an observation, a registered nurse and a respiratory therapist did not wear gowns while providing high-contact care, which is contrary to the Centers for Medicare & Medicaid Services (CMS) guidance on EBP. The facility's policy on isolation precautions did not include EBP procedures, and the Infection Preventionist acknowledged the lack of policy updates and implementation of EBP, which could lead to the spread of multidrug-resistant organisms (MDRO). In another incident, a licensed vocational nurse did not follow sterile technique during urinary catheterization for a resident with anoxic encephalopathy and neurogenic bladder. The nurse used non-sterile gloves to handle sterile supplies, compromising the sterile field. The facility's policy required the use of sterile technique for catheter insertion, but this was not adhered to, increasing the risk of infection. Additionally, the same nurse failed to perform hand hygiene after attempting catheterization, which is a breach of the facility's infection control policy and the Centers for Disease Control and Prevention (CDC) guidelines. The nurse did not wash hands after resident contact, which is essential to prevent the spread of infections. The facility's policy emphasized the importance of hand hygiene in all patient care activities, but this was not followed, posing a risk of urinary tract infections.
Failure to Maintain Comprehensive Respiratory Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was in place for a resident with a tracheostomy and ventilator-dependent status. The resident, who was admitted with diagnoses including dependence on a ventilator, tracheostomy status, and bronchopulmonary dysplasia, did not have an active care plan addressing his respiratory needs. This oversight was identified during a review of the resident's clinical records, which revealed the absence of a care plan for his respiratory status, despite the presence of physician's orders for tracheostomy care and other related interventions. Interviews with the Director of Respiratory Therapy and the Director of Case Management confirmed the lack of an active respiratory care plan. The Director of Case Management acknowledged that the care plan had been mistakenly closed out after someone indicated the goal was met, leading to its inactivation. The facility's policy requires comprehensive and individualized care plans, but this was not adhered to in the case of the resident, resulting in a deficiency in care planning for his respiratory needs.
Controlled Medication Verification Process Not Completed
Penalty
Summary
The facility failed to ensure the proper verification process for controlled medications was completed accurately for two of seven medication carts. This deficiency was identified during observations and interviews with a Licensed Vocational Nurse (LVN) and the Chief Nursing Officer (CNO). The Controlled Substance Inventory Count (CSIC) forms for Valtoco Nasal Spray, a medication used to treat episodes of uncontrolled bodily movements, were found to have missing signatures from both oncoming and off-going nurses during shift changes. Specifically, on multiple occasions in December 2024 and January 2025, signatures were missing from the CSIC forms, indicating that the required verification process was not followed. The facility's policy and procedure for controlled substance management, which mandates that both the nurse leaving the shift and the nurse coming on duty must verify and document the count of controlled substances, was not adhered to. The CNO confirmed that the policy was not followed, which had the potential to lead to the diversion of controlled medications in a population of 50 patients. The failure to complete the verification process accurately was confirmed by LVN 2, who acknowledged the missing signatures and the oversight in the procedure.
Non-compliance with PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of PRN psychotropic medications, specifically lorazepam, for a resident. The resident, who had a complex medical history including tracheostomy status and hypoxic ischemic encephalopathy, was prescribed lorazepam for agitation with an order that exceeded the 14-day limit without documented rationale from the prescriber. The medication order was active for 20 days, from December 20, 2024, to January 8, 2024, and the resident received the medication multiple times during this period for agitation. Interviews with the facility's pharmacist and Chief Nursing Officer (CNO) revealed that there was no documented rationale for extending the PRN order beyond 14 days, which is required by regulation. The pharmacist acknowledged the irregularity of the order duration, and the CNO confirmed the absence of a policy and procedure regarding PRN psychotropic medication orders. The facility relied on the pharmacist to ensure compliance with regulations, but this oversight led to a deficiency in medication management for the resident.
Expired Medication Found in Emergency Kit
Penalty
Summary
The facility failed to ensure proper medication management when a bottle of Humulin R, a short-acting insulin, was found expired by 33 days in one of the four medication emergency kits (E-Kits). This was discovered during an observation and interview with the Charge Nurse in the medication storage room. The Charge Nurse confirmed the expiration and acknowledged the potential risk of administering expired medication during an emergency, which could be detrimental to a resident's health and safety. Further investigation revealed that the facility's policy and procedure for medication management, which mandates the removal and appropriate disposal of expired medications, was not followed. The Chief Nursing Officer confirmed the policy breach. Additionally, the in-house Director of Pharmacy stated that nurses are responsible for ensuring medications are not expired and should notify the pharmacy for replacements. Despite checks documented in the Subacute Charge Nurse Report, the expired medication was not identified or replaced, indicating a lapse in the medication management process.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to adhere to safe and sanitary food storage practices, as observed during a survey. In the dry storage area, seven onions were found labeled with an expired use-by date, indicating they were three days past their intended use. The kitchen staff member, CK 1, acknowledged the oversight and removed the onions from the storage area. Additionally, in the walk-in freezer, a large bucket of ice cream was discovered without any labeling to indicate the date it was received or its intended use-by date. CK 1 admitted uncertainty about when the ice cream was purchased, noting it was intended for an employee Christmas party but was not labeled as such. The Registered Dietician (RD 1) confirmed that all food items should be labeled with the date of receipt and a use-by date, and that food for employee events should be clearly marked to distinguish it from resident food. RD 1 also stated that onions could be stored for up to 30 days in the dry storage area, provided they were properly labeled. A review of the facility's policy on food labeling and dating revealed that a labeling and dating machine was supposed to be used to ensure food items were rotated and used by their expiration dates. These lapses in food storage practices had the potential to compromise food integrity and pose a risk of foodborne illness to residents.
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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) |
|---|---|---|---|---|
| Loma Linda Post Acute | 1.4 mi | ★★★★★ | 0 | 0 |
| Asistencia Villa Healthcare Center | 1.6 mi | ★★★★★ | 18 | 0 |
| Heritage Gardens Health Care Center | 1.7 mi | ★★★★★ | 18 | 0 |
| Brookside Healthcare Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Madison Grove Post Acute | 3.2 mi | ★★★★★ | 17 | 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.