Laguna Honda Hospital & Rehabilitation CTR D/P SNF

In the surveyor’s words

From the most serious findings on record at Laguna Honda Hospital & Rehabilitation CTR D/P SNF, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 1, 2025

  Based 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. Findings: A record review of Resident 11's History and Physical (H & P, an assessment completed by a medical provider) dated 5/7/25 indicated, Resident 11 was admitted with multiple diagnoses including Vascular dementia (A usually progressive condition marked by the development of multiple cognitive deficits with abrupt or gradual… […]

• Actual harm, isolatedF600May 3, 2024

  Based 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. Findings: A review of the facility policy titled ABUSE AND NEGLECT PREVENTION, IDENTIFICATION, INVESTIGATION, PROTECTION, REPORTING AND RESPONSE, last revised on 11/14/23, indicated that sexual abuse is defined as non-consensual sexual contact of any type with a resident. One of the stated purposes of the policy is to provide clinical interventions to prevent and minimize abuse or neglect . The policy further indicated that In cases of allegations of abuse . […]

• Actual harm, isolatedF600Apr 19, 2024

  Based 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. having no self-respect Findings: Resident 1 was admitted with multiple diagnoses including paraplegia (loss of inability to move the legs) and chronic pain (long-term pain). Review of Resident 1's record, titled Minimum Data Set (MDS is a standard assessment tool), dated 12/1/24, indicated his memory, reasoning abilities were intact. […]

• Actual harm, isolatedF689Feb 28, 2024

  Based 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). […]

• Actual harm, isolatedF656Feb 9, 2024

  Based 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… […]