Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Community Convalescent Center Of San Bernardino during CMS and state inspections, most recent first.
The facility did not implement timely infection control actions after a positive Legionella water test, failed to properly label an enteral feeding system for a resident, and did not ensure respiratory equipment was labeled with change dates, resulting in increased risk of infection for residents with complex medical needs.
A resident with chronic respiratory failure and a tracheostomy received two intravenous antibiotics, but the ICP nurse did not properly analyze or document whether infection criteria were met according to the facility's antimicrobial stewardship policy. Required analysis and documentation were incomplete, and the DON and ICP nurse could not confirm if the antibiotics were used for a true infection, resulting in a failure to follow established procedures.
Seven packets of expired protein supplement were found in a medication cart during an inspection with an RN, who confirmed they should have been disposed of. Review of facility policy with the DON showed that expired medications and supplements should not be stored in the cart, and the policy was not followed.
A CNA did not wash her hands before handling a meal tray for a medically compromised resident, removed food from the tray with bare hands, and failed to heat the food to the required 165°F using a thermometer. Staff interviews and facility policy confirmed that these actions did not meet established hand hygiene and food safety protocols.
A resident with chronic respiratory failure and a tracheostomy was physically abused by a School Licensed Vocational Nurse (S/LVN) who slapped the resident's hand. The incident was observed by a School District Teacher and later reported to the Director of Nursing (DON) and the Administrator (Admin). The Admin confirmed the abuse after reviewing the incident.
The facility failed to implement its water management program, affecting all 18 residents. Key personnel, including the Plant Operation Manager, Facility Director, Infection Preventionist, and Administrator, were either unaware of or did not take responsibility for conducting the necessary water system assessments and testing.
Failure to Implement Infection Control Measures and Proper Labeling
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several key areas. After a positive water test for Legionella was performed, the results and recommended actions were not communicated to the nursing department, administration, or infection prevention staff. The Director of Facility Management was aware of the positive test but did not notify the appropriate parties, and no action plan was initiated to remediate the affected water sources. As a result, residents, including those with tracheostomies, were exposed to Legionella-contaminated water for over two months without any corrective measures being taken. Additionally, an open enteral feeding system for a resident was not labeled with the correct date and time. The feeding bag at the resident's bedside was marked with an incorrect date, and there was no indication of the time it was prepared or the nurse's initials. The nurse confirmed the labeling was incorrect and acknowledged that the system should be changed every 24 hours, as per facility policy, to prevent bacterial growth and infection. Furthermore, sterile respiratory water, a tracheostomy mask, and a nebulizer used for the same resident were not labeled with the date and time they were last changed. The respiratory therapist could not determine when these items had last been replaced, and the infection prevention nurse confirmed that these items should be labeled and changed according to the facility's policy. The lack of proper labeling and adherence to change schedules for respiratory equipment and enteral feeding systems increased the risk of infection for residents with compromised health conditions.
Failure to Implement Antibiotic Stewardship Policy and Analyze Antibiotic Use
Penalty
Summary
The facility failed to implement its policy and procedure on antibiotic stewardship for one of six sampled residents reviewed for antibiotic use. Specifically, the Infection Control Preventionist (ICP) nurse did not accurately analyze collected data to identify the purpose and rationale for antibiotic use, nor did she confirm whether the clinical conditions met the criteria for appropriate antibiotic therapy. For the resident in question, who had chronic respiratory failure with hypoxia and was tracheostomy dependent, physician orders included two powerful intravenous antibiotics for indications such as UTI and a resistant bacterial infection. However, documentation and analysis using the McGeer Criteria were incomplete, with key fields left blank and no clear determination of whether infection criteria were met. During interviews and record reviews, it was revealed that the ICP nurse and the Director of Nursing (DON) could not locate documented evidence in the clinical records to support whether the antibiotics were used for a true infection. The facility's antimicrobial stewardship policy required monitoring, analysis, and presentation of antimicrobial use data, but this process was not followed. The ICP nurse acknowledged that she should have conducted a thorough analysis to confirm appropriate antibiotic use, but this was not done, and the facility's policy was not adhered to.
Expired Protein Supplements Found in Medication Cart
Penalty
Summary
During an inspection of a medication cart, seven packets of protein supplement were found to be expired by 60 days but still available for resident use. The expired supplements were discovered during a concurrent observation and interview with a registered nurse, who confirmed that the items should have been disposed of and not kept in the medication cart. A review of the facility's policy and procedure on safe storage of medications indicated that medications must be stored under appropriate conditions to maintain their integrity and availability. The Director of Nursing acknowledged that the facility's policy was not followed, resulting in expired medications and supplements being present in the medication cart.
Failure to Follow Hand Hygiene and Food Reheating Protocols During Meal Preparation
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow proper hand hygiene and food handling protocols when preparing a meal for a medically compromised resident. The CNA did not wash her hands before entering the kitchen or before handling the resident's meal tray. She removed hard-boiled eggs from the tray with her bare hands and used her hands to check the temperature of the food after partial heating in the microwave. The CNA did not use the thermometer provided to ensure the food was heated to the required 165 degrees Fahrenheit, instead relying on touch and resident preference to determine if the food was warm enough. Interviews with facility staff, including the Dietary Services Supervisor, Licensed Vocational Nurse, and Registered Dietitian, confirmed that the established procedure requires food to be reheated to 165 degrees Fahrenheit and that handwashing is mandatory before handling food or clean utensils. Review of the facility's Food and Nutrition Services Standard Operating Procedure corroborated these requirements. The failure to adhere to these protocols placed the resident at risk for food-borne illness.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect Resident 1 from physical abuse when a School Licensed Vocational Nurse (S/LVN) slapped the resident's hand. Resident 1, who had chronic respiratory failure and a tracheostomy, was waiting in the entrance of the facility for transport to school. The incident was observed by a School District Teacher who saw the S/LVN tap Resident 1's hand as the resident reached for his tracheostomy. When Resident 1 reached for his tracheostomy again, the S/LVN slapped the resident's hand. The teacher did not intervene at the moment but later reported the incident to the Director of Nursing (DON), who then reported it to the Administrator (Admin). The teacher and the DON were unavailable for interviews during the investigation. The Administrator, who is also the facility's abuse coordinator, confirmed the incident after interviewing the teacher and reviewing the documents describing the event. The facility's policy and procedure titled 'Notification and Exercise of Rights and Responsibilities' indicates that residents should receive care in a safe setting, free from any form of abuse. The Admin determined that the S/LVN had physically abused Resident 1, causing the resident to suffer abuse and fear.
Failure to Implement Water Management Program
Penalty
Summary
The facility failed to implement its water management program, affecting all 18 residents. The policy titled 'Utility Water Safety Management,' last reviewed in February 2024, outlines the need for a water management program to reduce the risk of Legionnaires' disease. The program should include control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and water endpoint testing for pathogens. However, interviews revealed that the Plant Operation Manager was unaware of any water testing conducted, and the Facility Director confirmed that no assessment of the facility's water system had been performed. The Infection Preventionist and the Director of Nursing both indicated that they believed the responsibility for the water management assessment fell under the Engineering Department's purview. The Administrator stated that the water management plan was managed by the Engineering Department but admitted that the assessment could not be found and should be onsite. This lack of coordination and communication among the facility's staff led to the failure to implement the water management program, thereby not adhering to the facility's policy and potentially putting residents at risk. The deficiency was identified through multiple interviews with key personnel, all of whom indicated a lack of awareness or responsibility for the water management assessment.
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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 San Bernardino
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Hospital Of San Bernardino Dp Snf | 0 mi | ★★★★★ | 19 | 0 |
| Arrowhead Springs Healthcare | 2.3 mi | ★★★★★ | 0 | 0 |
| Medical Center Convalescent Hospital | 2.3 mi | ★★★★★ | 13 | 0 |
| Valley Healthcare Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Waterman Canyon Post Acute | 2.3 mi | ★★★★★ | 2 | 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.