Loma Linda Post Acute

    25383 Cole St, Loma Linda, CA, 92354
    3.5 · 45 reviews
    • Assisted living
    • Memory care
    • Skilled nursing
    AnonymousLoved one of resident
    2.0

    Caring staff understaffed unsafe chaotic

    I had a mixed experience. Many staff - nurses, CNAs, PT, speech and activities - were caring, professional and helped restore strength; the rehab program and homey atmosphere were highlights. But chronic understaffing and poor management caused long response times, medication delays, cleanliness and safety problems (bed sores, urine incidents, reported lice, and some verbal/physical mistreatment), plus chaotic discharge and billing. I'd use them for short-term rehab only if I closely monitor care and document everything; I wouldn't trust them for long-term placement without major improvements.

    Pricing

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    3.53 · 45 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      3.1
    • Staff

      3.3
    • Meals

      2.7
    • Amenities

      2.8
    • Value

      1.0

    Pros

    • Strong rehabilitation services (PT, OT, Speech therapy)
    • Professional and proficient clinical staff in many departments
    • Individual staff members frequently described as caring, compassionate, and attentive
    • Caring CNAs and nursing staff praised in many accounts
    • Home-like, family atmosphere reported by several reviewers
    • Activities/recreation program praised (specific praise for Adriana, music, grandchildren activities)
    • Reliable, careful, on-time transportation (preheated van, sweet driver)
    • Excellent primary doctor and strong medical resources noted
    • Private rooms and private family areas available
    • Daily check-ins and consistent symptom/pain management reported by some families
    • Helpful, kind head nurse mentioned in multiple reviews
    • Facility can support transitions back to independent living
    • Supportive Sub-Acute Care team reported to improve transitions
    • Facility described as clean and well-kept in multiple reviews
    • Staff who go above and beyond (respiratory, rehab, activities) called out
    • Comforting environment and dignity-preserving care reported
    • Notarization and other extra services available
    • Some reviewers highly recommend the facility and plan to return

    Cons

    • Highly inconsistent standard of care across shifts and units
    • Frequent complaints about management, administration, and social worker
    • Allegations of neglect: patients left unattended, long response times, sitting in urine
    • Serious safety incidents reported (patient found naked, dehydration, ICU admission, bed sores)
    • Reports of physical abuse or rough handling by some CNAs (bruises, slapped hand)
    • Head lice infestation among staff reported
    • Understaffing and overworked staff leading to long wait times
    • Poor communication from management and during discharge/transition
    • Billing issues and Medi-Cal submission or billing disputes
    • Facility described as run down, small, and overcrowded by some reviewers
    • Cleaning lapses (room not mopped for weeks) and inconsistent cleanliness
    • Late medications and delayed emergency responses noted
    • Inconsistent dining quality—meals sometimes excellent but often poor
    • Complaint handling seen as inadequate; some families escalated to county/state or Ombudsman
    • Few phones/poor call-response systems reported (e.g., 3 phones for many patients)
    • Disorganized discharge processes and denial of after-hours calls
    • Variable competence among staff—some wonderful individuals but many seen as incompetent
    • Perception that facility handles complaints to its convenience rather than resident advocacy
    • Incidents resulting in families relocating loved ones after short stays
    • Inconsistent attention to infection control and staff health screening
    • Uneven experience depending on unit (rehab/subacute better than long-term in multiple reports)
    • Emotional distress caused to families due to unpredictable care quality
    • Some reviewers would not recommend placing loved ones there
    • Reports of management making excuses and lack of accountability
    • Concerns that low pay/overwork contribute to poor staff performance

    Summary review

    Overall sentiment across these reviews is highly mixed and polarized: many reviewers emphatically praise specific departments, teams, and individual staff members—especially rehabilitation (PT/OT/Speech), select nurses, CNAs, and the activities/recreation staff—while a significant number of reviews describe serious care failures, neglect, and administrative mismanagement. The pattern that emerges is one of wide variability: when the right staff are on duty and in certain units (notably rehab and sub-acute care), residents receive excellent, attentive, and professional care that families deeply appreciate. Multiple reviewers single out physical and speech therapy teams, respiratory staff, and activities personnel (Adriana mentioned by name) as exceptional, and several families report that those services helped residents regain strength, dignity, and independence.

    At the same time, an alarming set of safety and quality-of-care concerns recur across reviews. Allegations include patients being left unattended for extended periods, long call-button response times, residents found in unsafe or undignified conditions (urine on the floor, naked on the floor), severe dehydration leading to ICU admission, open diaper rash and bed sores, and reported rough handling or even physical abuse by some CNAs (bruises, slapped hands). These incidents are severe enough that multiple families reported relocating loved ones quickly or filing complaints with county or state authorities. Reviewers describe the facility as inconsistent: clean and comfortable at times, run down and understaffed at others.

    Management and administrative issues are another dominant theme. Numerous reviewers call out poor communication, disorganized discharge processes, billing and Medi-Cal submission problems, an unhelpful social worker, and a clueless or uncaring administrator. Complaint handling is frequently criticized—families report needing to document everything, that on-site complaint responses can feel convenient for the facility rather than resolute, and that escalation to Ombudsman or regulators was necessary. Several operational problems are specifically noted: inadequate phone/access systems (e.g., very few phones for many patients), denial of after-hours calls, and scheduling or staffing practices that contribute to long wait times and inconsistent oversight.

    Facility conditions and infection-control concerns are split in the reviews. Some families describe the facility as clean, well-kept, and comfortable, while others report rooms that are not cleaned for weeks, a run-down appearance, overcrowding, and even a reported head-lice problem among staff. Food and dining also receive mixed comments: a few reviewers praise meals and special events (Mother’s Day lunch, homemade soup), but many describe food inconsistency—sometimes good, other times described as slop or cafeteria-style fare.

    A recurrent explanation offered by reviewers for the inconsistency is staffing pressures: staff are described as overworked and underpaid, which reviewers believe contributes to mistakes, slow responses, and variable compassion. The net effect reported by families is unpredictable care quality that depends heavily on which staff are on duty and which unit the resident is admitted to. Rehab and short-term/sub-acute stays appear to produce the most positive outcomes; long-term care and Medicaid-related stays seem more likely to be associated with the negative reports, although this is not universal.

    Bottom line: Loma Linda Post Acute receives strong, specific praise for its rehabilitation services, some compassionate clinical staff, and an effective activities/transportation program. However, the facility also has repeated, serious, and specific complaints regarding neglect, safety incidents, management failures, inconsistent cleanliness, and poor complaint resolution. Prospective residents and families should be aware of high variability in care quality, consider visiting and asking targeted questions about staffing levels, complaint procedures, infection control, and discharge/transition processes, and document everything. If placing a vulnerable loved one, follow up closely during the first days and be prepared to escalate concerns promptly if substandard care is observed.

    Location

    Map showing location of Loma Linda Post Acute

    About Loma Linda Post Acute

    Loma Linda Post Acute is an older care facility that focuses on post-acute and long-term care, sitting in California and offering 83 certified beds with a daily average of around 77 residents, and people say the place is immaculate even though it's been around for a while. The facility has semi-private rooms meant to give comfort and privacy, and it tries to make things feel home-like for everyone staying there, whether someone needs help for just a short time after a hospital stay or plans to be there longer. They provide 24-hour skilled nursing services and offer therapies and support aimed at helping people get back their strength and independence, which means there are exercise programs and activities in the dining hall, plus social services, and they'll help with rehabilitation for those recovering from health problems. There are some deficiencies on record, including issues with following care orders, infection control, and timely assessment reporting-inspection reports have documented a total of 33 deficiencies, and some of them are related to infection processes and planning care. The nurse turnover rate is pretty high at 42.6%, and nurse staffing averages about 4.34 hours per resident each day, which may affect how much hands-on care each resident gets. Management's changed hands a few times recently, with Frederick Apt, Joel Dimaunahan, Kenneth Jardine, Joshua Jergensen, Trevor Lords, John Mitchell, and Shantharam Pai each holding different managerial roles, and ownership comes from Loma Linda Master Tenant LLC, with ties to Pacs Group and several other holding companies and individuals. The facility runs as a for-profit limited liability company and strives to improve post-acute care operations, partly by relying on PACS Services to support the local staff so they can focus on residents' well-being and quality of life. CMS has given the facility a 4-star rating under Medicare, which means it's above average though not perfect. There's a focus on personalized care, and the goal is to be a good employer for post-acute care professionals and to offer thoughtful programs that promote community among both staff and residents, but with deficiencies in record-keeping, infection control, and care planning, families might want to review the inspection reports for a complete picture.

    People often ask...

    State of California Inspection Reports

    2

    Inspections

    0

    Type A Citations

    3

    Type B Citations

    2

    Years of reports

    05 Jan 2024
    Identified deficiencies in various areas such as physical plant, staff records, and resident records during the inspection. Medical related services were found to be in compliance.
    • § 87411(c)(1)
    • § 87412(a)(11)
    • § 87457(c)(1)
    03 Feb 2023
    Inspection identified no deficiencies and all areas of the facility were found to be clean and in good condition.

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