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Inspection visit

Inspection

LAGUNA HILLS HEALTH AND REHABILITATION CENTERCMS #0561102 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 1) was free from abuse. * CNA 5 borrowed $500 from Resident 1, which caused Resident 1 to feel worried and emotional when the money was not returned on time. CNA 5 then asked Resident 1 to lie and say the money was payment for work CNA 5 had done for the resident. This failure negatively affected Resident 1's emotional wellbeing.Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation Prevention Program revised 4/2021 showed the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation Review of the facility's SOC 341 dated 12/29/25, showed Resident 1 loaned CNA 5 $500, and the money had not been fully returned. Medical record review for Resident 1 was initiated on 1/29/26. Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 7/14/25, showed Resident 1 had the capacity to understand and make medical decisions. The H&P further showed the resident 1 had diagnoses including generalized anxiety disorder. Review of Resident 1's SBAR Communication Form dated 12/29/25, showed there was a change in condition regarding the resident lending money to a staff member. Review of Resident 1's care plan dated 12/29/25, showed the resident was at risk for emotional distress and anxiety related to a recent incident when the resident voluntarily lent money to CNA 5 out of pity. Review of Resident 1's Progress Note dated 12/29/25, showed the ADON met with Resident 1 to discuss the matters of a CNA, who Resident 1 had stated borrowed $500 dollars. Further review of the Progress Note showed Resident 1 informed the ADON CNA 5 had expressed to Resident 1 she had financial struggles which caused Resident 1 to feel bad, so she loaned CNA 5 $500. Resident 1 further stated to the ADON CNA 5 paid Resident 1 $250 a week ago, but Resident 1 was worried because she had not received the rest of the money. Review of Resident 1's MDS assessment dated [DATE], showed the resident was cognitively intact. On 1/29/26 at 1315 hours, an interview was conducted with Resident 1. Resident 1 stated CNA 5 was one of the best CNAs she ever had. Resident 1 stated CNA 5 told her about the personal and financial hardships she was facing, and had offered CNA 5 $500 to help with the financial hardships. Resident 1 stated CNA 5 informed her she would pay her back in two weeks. Resident 1 stated CNA 5 paid her $250 a week later. Resident 1 stated CNA 5 then blocked her phone and stopped communicating. Resident 1 stated it was getting close to Christmas time and she was getting worried. Resident 1 stated she did not want to report it but one of the nurse supervisors overheard her talking about it on the phone with her sister. Resident 1 stated CNA 5 then contacted her and asked her to lie and say she had done work for her. Resident 1 stated it made her feel emotional. On 2/2/26 at 0949 hours, an interview was conducted with the SSA. The SSA stated Resident 1 informed them CNA 5 spoke to Resident 1 about CNA 5's struggles outside of work. The SSA stated Resident 1 felt sad about CNA 5's situation and did not want CNA 5 to get in trouble, but she just wanted the rest of the money back. Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 056110 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 2/2/26 at 1010 hours, an interview, medical record review and concurrent facility document review was conducted with the ADON. Review of the Employee handbook dated June 2024 showed under the section of giving and receiving gifts showed, staff cannot solicit or accept tips, gifts, loans, gratuities, bequests, or any item of value from any resident, family member, or visitor or any other person conducting business with the facility. Employees were also not allowed to purchase items or borrow money from residents. Any violation of the facility's gifts and gratuities policy could result in disciplinary action. The ADON stated every new employee receives a copy of the employee handbook upon hire. The ADON stated it was also included in the abuse training. On 2/4/26 at 1730 hours, an interview was conducted with the DON and the Administrator. The Administrator stated CNA 5 should not have taken the money from the resident. Cross Reference to 684 Event ID: Facility ID: 056110 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to conduct the status post change of condition assessments for one of nine sampled residents (Resident 1). * The facility failed to conduct any follow up nursing assessments on Resident 1 who had a change of condition involving an incident where a CNA borrowed money from Resident 1. This failure posed the risk for changes in Resident 1's psychosocial well-being not identified and potentially delayed the necessary care and treatment for the resident.Findings: Medical record review for Resident 1 was initiated on 1/29/26. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 1's H&P examination dated 7/14/25, showed Resident 1 had the capacity to understand and make medical decisions. Resident 1 had diagnoses including generalized anxiety disorder. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 was cognitively intact. Review of Resident 1's SBAR Communication Form dated 12/29/25, showed there was a change in condition regarding Resident 1 lending money to a staff member. Review of Resident 1's Care Plan Report initiated on 12/29/25, showed a care plan problem to address Resident 1's risk for emotional distress/anxiety related to recent incident of voluntarily lending money to CNA out of pity. Review of Resident 1's Progress Notes dated 12/29/25, showed the ADON met with Resident 1 to discuss the matters of a CNA who Resident 1 had stated borrowed $500 dollars from her. Further review of the progress notes showed Resident 1 stated to the ADON CNA 5 had expressed to Resident 1 she had financial struggles which caused Resident 1 to feel bad, so Resident 1 loaned CNA 5 the money. Additional review of the progress notes showed Resident 1 stated CNA 5 had paid Resident 1 back the $250 a week ago; however, Resident 1 was worried because she had not received the rest of the money. On 2/2/26 at 1450 hours, a concurrent interview and medical record review was conducted with the ADON. The ADON stated following a change in condition, nurses are required to conduct nursing assessments related to the change in condition every shift for 72 hours. The ADON stated the purpose of the post event nursing assessments was to address any potential complications from the specific change in condition. Review of Resident 1's progress notes did not show any post event nursing assessments and monitoring related to the change of condition incident. The ADON verified the nursing assessments were not done. Cross Reference to F602. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056110 If continuation sheet Page 3 of 3

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Citations

2 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0602GeneralS&S Dpotential for harm

    F602 - The resident has the right to be free from abuse, neglect, misappropriation of re

    Protect each resident from the wrongful use of the resident's belongings or money.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

FAQ · About this visit

Common questions about this visit

What happened during the February 4, 2026 survey of LAGUNA HILLS HEALTH AND REHABILITATION CENTER?

This was a inspection survey of LAGUNA HILLS HEALTH AND REHABILITATION CENTER on February 4, 2026. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at LAGUNA HILLS HEALTH AND REHABILITATION CENTER on February 4, 2026?

Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from the wrongful use of the resident's belongings or money."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.