Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Hospital Of San Bernardino Dp Snf during CMS and state inspections, most recent first.
Failure to follow a fall care plan intervention resulted in a resident falling from bed. The resident, who had respiratory failure and cardiac arrest diagnoses and was dependent for toileting hygiene and bathing, was being prepared for a shower when a CNA left to get a shower bed without securing the bedside rails. Seconds later, the resident was found on the floor next to the bed after an unwitnessed fall, and the Admin acknowledged the fall prevention plan was not followed.
A resident dependent on ventilator support was not properly reconnected to the ventilator after a shower, as staff failed to resume ventilation from standby mode. The oversight went unnoticed by the respiratory therapist, CNAs, and RN involved in the resident's care. The ventilator remained inactive for over three hours, resulting in the resident being found unresponsive and requiring emergency intervention and transfer to the ICU.
A resident with multiple medical conditions who was fully dependent for mobility fell and sustained a head laceration when the attachment holding the bar and scale of a Hoyer lift became disconnected during a transfer. Both the LVN and CNA involved believed the attachment was secure, but as the resident was moved away from the bed, the connection failed. Maintenance found no equipment defects, and the facility determined the incident was caused by improper securing of the lift attachment, in violation of safe patient handling procedures.
Multiple residents with G-tubes and suction devices did not have required labeling on their feeding and suction equipment, and staff failed to use or properly wear PPE such as gowns and gloves during medication administration and resident transfers, contrary to facility infection control policies and Enhanced Barrier Precautions.
Two residents at risk for pressure ulcers did not receive timely repositioning as required by their care plans and facility policy, with documented gaps of several hours between turns. Additionally, a low air loss mattress for one resident was set to an incorrect weight range, contrary to physician orders and manufacturer guidelines. Staff interviews and record reviews confirmed these failures in pressure ulcer prevention practices.
A resident with severe contractures and multiple complex medical conditions did not receive physician-ordered passive ROM exercises as specified in the care plan, with multiple shifts lacking documentation or evidence of care provided. CNA and DON confirmed the omission and acknowledged that facility policy requiring restorative care, including ROM, was not followed.
An LVN left 12 medications unattended and unsecured on a computer desk at the bedside of a resident while leaving the room to retrieve a blood pressure cuff. The medications, which included both oral and topical drugs, were accessible to anyone entering the room. Facility policy and the DON confirmed that medications must be secured at all times and not left unattended.
Two residents with complex medical needs were found sharing a room without a privacy curtain between their beds, contrary to facility policy. Staff interviews confirmed that curtains are required for visual privacy, but neither the charge nurse nor Environmental Services could explain the absence or duration of the missing curtain. The DON and Administrator acknowledged that the policy requiring privacy curtains was not followed.
The facility failed to maintain infection control practices, as residents on transmission-based precautions were not adequately separated from others, and visitors were not properly educated on PPE use. A resident was observed less than three feet from another on isolation, a visitor left an isolation room without removing PPE, and two residents shared a room without proper separation, violating federal and CDC guidelines.
The facility failed to follow CDC guidelines for droplet precautions, as observed in a shared room where a resident on droplet isolation was not properly separated from another resident. The Infection Preventionist and Neuro Care Unit Manager acknowledged that the facility's policy did not reflect current guidelines, leading to a potential risk of infection spread.
A resident with cerebral palsy, tracheostomy, and gastrostomy was placed in a soft wrist restraint without informed consent. The facility's policy requires informed consent for restraint use, which was not obtained, leading to the resident and their representative not being fully informed about the care provided.
A resident with a gastrostomy, heart failure, and tracheostomy received excessive enteral nutrition due to a failure to stop the feeding pump as ordered. The feeding pump continued to run, infusing 1512 ml instead of the prescribed 1040 ml. This discrepancy was confirmed by an LVN, and the facility's policy for accurate administration of formula was not followed, potentially increasing the risk of aspiration.
A licensed nurse left a medication cart unlocked and unattended in the North wing, contrary to the facility's policy requiring secure storage of medications. The nurse acknowledged the oversight, and the NeuroCare Unit Manager confirmed the policy breach, highlighting the importance of keeping medications locked to prevent unauthorized access.
Failure to Follow Fall Care Plan Led to Resident Fall
Penalty
Summary
The facility failed to implement a fall care plan intervention for one resident who was identified as a fall risk. The resident’s face sheet showed diagnoses including respiratory failure and cardiac arrest. The resident’s fall care plan, initiated on June 14, 2024, included an intervention to assess for the need for side rails or any. The resident’s MDS dated April 2, 2026, indicated the resident was dependent for toileting hygiene and shower/bathing self. On April 20, 2026, the resident had an unwitnessed fall at about 9:30 AM and was found lying on the floor next to the bed, facing up, with the head on top of the IV pole and the right side rail down. A CNA stated she was preparing the resident for a shower, forgot to lock or secure the bedside rails when she left to get the shower bed, and returned seconds later to find the resident on the floor. The Facility Administrator reviewed the facility’s Fall Prevention Program and acknowledged that the individualized interdisciplinary fall prevention/reduction plan of care was not followed.
Failure to Resume Ventilator Support After Shower Leads to Resident Respiratory Arrest
Penalty
Summary
A deficiency occurred when a ventilator-dependent resident was not safely reconnected to their ventilator following a shower. The resident, who had a history of sepsis, anoxic brain injury, encephalopathy, and chronic respiratory failure, was transferred from the ventilator to an Ambu bag for the duration of the shower. Upon returning to the room, the Respiratory Therapist (RT) reconnected the resident to the ventilator but failed to resume ventilation from standby mode, leaving the ventilator inactive. Multiple staff members, including Certified Nursing Assistants (CNAs) and a Registered Nurse (RN), were involved in the resident's care during this period. The RN, who was overseeing 28 residents including 15 on ventilators, did not check the ventilator or its settings after the resident returned from the shower. The CNAs assisted with the shower and observed the reconnection process but did not verify that the ventilator was turned on. The RT stated that they resumed ventilation from standby mode, but ventilator logs and a review by the Bio Med Technician confirmed that the ventilator remained on standby for over three hours. As a result of the ventilator not being activated, the resident was found unresponsive, without a pulse or respirations, and a code blue was initiated. The resident required emergency intervention and was subsequently transferred to the ICU for close observation and treatment. Facility records and interviews confirmed that the ventilator was functioning properly but was not taken out of standby mode after the shower, directly leading to the resident's respiratory arrest.
Resident Fall Due to Improper Hoyer Lift Attachment
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident was free from accident hazards and did not provide adequate supervision during a transfer using a Hoyer lift. The incident involved a resident with significant medical needs, including anemia, chronic respiratory failure, and a history of cerebrovascular accident, who was fully dependent on staff for mobility. During a transfer to weigh the resident, the attachment holding the bar and scale of the Hoyer lift became disconnected, resulting in the resident falling to the floor and sustaining a head laceration that required sutures and ICU observation. Record reviews and interviews revealed that both the LVN and CNA involved in the transfer believed the attachment was secure before lifting the resident. However, as the resident was being moved away from the bed to obtain an accurate weight, the attachment suddenly disconnected. The maintenance staff later demonstrated that the lift's interlocking hooks and safety latch were functioning properly and found no mechanical defects or wear on the equipment. The facility's investigation concluded that the primary cause of the incident was the separation of the attaching C clasp on the scale portion of the Hoyer lift from the C clasp of the lifting strap, likely due to improper securing of the attachment. The facility's policy and the lift manufacturer's instructions require staff to ensure all lifting accessories are correctly and securely applied before use. Despite staff training and annual competency checks, the staff did not follow these procedures, resulting in the resident's fall and injury. The clinical director confirmed that the facility's safe patient handling and mobility policy was not followed during this incident.
Infection Control Program Deficiencies Related to Labeling and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for multiple residents, as evidenced by several observed deficiencies. For one resident with a gastrostomy tube (G-tube), the feeding bottle and water flush bag were not labeled with the date and staff initials, contrary to facility policy requiring these items to be changed and labeled every 24 hours. Multiple staff, including an LVN, RN, and the Infection Preventionist (IP), confirmed the absence of required labeling, acknowledging that this omission made it difficult to determine when the equipment was last changed. Additionally, for ten residents with suction tubes connected to mechanical ventilators or artificial airways, the tubing was not labeled with the date and initials as required by policy. Observations revealed that suction tubing at the bedside of these residents lacked any labeling, and both the respiratory therapist and IP confirmed this was not in compliance with facility procedures. The policy specified that disposable equipment, such as inline suction catheters, must be changed every 24 hours and labeled accordingly, but this was not followed. The facility also failed to ensure proper use of personal protective equipment (PPE) during high-contact care activities. Staff were observed administering medications through G-tubes and performing transfers without wearing gowns as required under Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. In one instance, a CNA wore a gown improperly, using it as an apron without the sleeves during a resident transfer after a shower. Interviews with staff and the IP confirmed that gowns and gloves were required during these activities, and that the observed practices did not align with facility policy or EBP guidelines.
Failure to Provide Timely Repositioning and Correct Pressure Mattress Settings for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatments and services to promote wound healing and prevent the development of pressure ulcers for two residents who were at risk. For one resident with a history of decubitus ulcers, tracheostomy dependence, and anoxic encephalopathy, documentation showed that repositioning was not performed or recorded every two hours as required by the care plan and facility policy. Specific gaps in repositioning were noted, including periods of 3.5 hours and over 9 hours without documented turns. The Director of Nursing confirmed that these lapses occurred and that elevating the head of the bed did not count as repositioning. Another resident, who had diagnoses including obesity, encephalopathy, tracheostomy, and a gastric feeding tube, was also not repositioned according to the prescribed two-hour schedule. Observations revealed that the resident remained on the same side for over three and a half hours, despite the turning schedule indicating otherwise. Staff interviews confirmed that the resident was not turned as required, and the care plan and facility policy both specified the need for repositioning every two hours for pressure ulcer prevention. Additionally, the same resident was found to be using a low air loss mattress that was programmed for an incorrect weight range, significantly higher than the resident's actual weight. Nursing staff were unaware of the incorrect setting, and it was acknowledged that the mattress should have been set to match the resident's weight to function properly. Facility policy required the consistent use of pressure-reducing devices as ordered, and staff confirmed the importance of correct mattress settings for effective pressure redistribution.
Failure to Provide Ordered Range of Motion (ROM) Services
Penalty
Summary
Nursing staff failed to provide necessary treatment and services to maintain or improve range of motion (ROM) for a resident with significant medical needs, including cerebral palsy, tracheostomy and gastrostomy dependence, severe contractures, and epilepsy. Physician orders and the resident's care plan specified that passive ROM exercises were to be performed on both upper extremities every AM shift and both lower extremities every night shift, as tolerated. However, a review of documentation revealed multiple instances where ROM activities were not completed or documented as required over several weeks. Certified Nursing Assistant (CNA) confirmed the missing documentation and acknowledged that ROM was not provided as ordered. The Director of Nursing (DON) and Administrator also verified that facility policy required restorative and supportive care, including ROM, to maintain joint mobility and prevent further deterioration. The DON stated that the policy was not followed and that nursing staff were expected to complete both the care and documentation as ordered.
Unattended Medications Left at Bedside by LVN
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to ensure the safety and security of medications by leaving 12 medications unattended and unsecured on a portable computer desk at the bedside of a resident. The LVN left the room to retrieve a blood pressure cuff, leaving the medications accessible to anyone who might enter the room. The medications included a variety of oral and topical drugs, such as glycopyrrolate, baclofen, amlodipine besylate, vitamin C, vitamin D3, famotidine, sennosides/docusate/sodium, carmex ointment, calcium carbonate, mineral oil, polyethylene glycol powder, and a multivitamin with minerals. The resident was present in the room at the time, and the LVN returned a few minutes later to administer the medications. During interviews, the LVN acknowledged that medications should not have been left unattended, especially given the proximity to a behavioral health unit. The Director of Nursing confirmed that facility policy requires all medications to be secured in locked storage or under the direct supervision of licensed staff at all times. A review of the facility's policy on safe storage of medications reiterated the requirement for medications to be secured to prevent unauthorized access and minimize the risk of diversion.
Failure to Provide Visual Privacy Due to Missing Curtain
Penalty
Summary
A deficiency was identified when two residents, both with significant medical needs including tracheostomy and gastrostomy tube dependence as well as seizure disorders, were found in a shared room without a privacy curtain separating their beds. During an observation, it was noted that there was no curtain in place to provide visual privacy between the two residents. Interviews with the charge nurse confirmed that the facility's standard practice for ensuring privacy is to have a curtain between residents, and the absence of the curtain was acknowledged. The charge nurse was unsure how long the curtain had been missing or why it was removed, and stated that Environmental Services is responsible for hanging curtains. Further interviews with Environmental Services staff did not clarify the reason for the missing curtain. Review of the facility's policy and procedures on resident privacy and confidentiality confirmed that nursing staff are required to use curtains to provide full visual privacy during care, toileting, treatments, and other times as needed. The Director of Nursing and the Administrator both confirmed that the facility's policy was not followed in this instance, as there was no curtain present to ensure the residents' privacy.
Infection Control Deficiencies in Resident Isolation Practices
Penalty
Summary
The facility failed to maintain proper infection control practices for several residents, leading to potential exposure to contagious diseases. Resident 51, who was not on transmission-based precautions, was observed less than three feet apart from Resident 69, who was on droplet and contact isolation for ESBL. Despite the facility's policy requiring a minimum separation of three feet between residents with and without transmission-based precautions, Resident 51 and Resident 69 were only 1.5 feet apart. This was confirmed by both the Licensed Vocational Nurse and the Infection Preventionist, who acknowledged that the policy was not followed. In another instance, the visitor of Resident 85, who was on droplet isolation, was not educated about the proper use of PPE. The visitor was seen leaving the isolation room without removing the PPE, contrary to the facility's policy. Interviews with the nursing staff revealed that while visitors were instructed to wear PPE upon entering the isolation room, they were not informed to remove it before leaving. This oversight was confirmed by the Director of Nursing, who stated that the policy required PPE to be removed before exiting the room. Additionally, Resident 57, who was not on transmission-based precautions, was observed sharing a room with Resident 85, who was on droplet precautions, without the necessary spatial separation or curtain drawn between them. The Infection Preventionist and the Neuro Care Unit Manager both acknowledged that federal regulations and CDC guidelines, which require a separation of at least three feet and the use of curtains in multi-bed rooms, were not adhered to. This failure to follow established guidelines increased the risk of infection transmission between residents.
Failure to Follow Droplet Precaution Guidelines
Penalty
Summary
The facility failed to adhere to the CDC guidelines for infection control, specifically regarding droplet precautions, for two residents. Resident 85, who was admitted with conditions including respiratory failure and an ESBL infection, was placed on droplet isolation. However, Resident 57, who shared a room with Resident 85, was not on any transmission-based precautions. During an observation, it was noted that the curtain between the two residents' beds was not drawn, which is a necessary measure to prevent the spread of infections transmitted by droplets. The Infection Preventionist (IP) and the Neuro Care Unit Manager (NM) both acknowledged that the facility's policy did not accurately reflect the CDC guidelines and federal regulations, which require spatial separation and the drawing of curtains between beds in shared rooms. The IP admitted to not knowing that the curtains should be drawn when cohorting a resident on droplet precautions. The facility's policy, dated May 1997, was outdated and did not include the necessary precautions, which could potentially lead to the spread of infectious diseases among residents and staff.
Failure to Obtain Informed Consent for Restraint Use
Penalty
Summary
The facility failed to ensure that a resident's rights were followed when a soft wrist restraint was applied to a resident without obtaining informed consent. The resident, who was admitted with conditions including cerebral palsy, tracheostomy, and gastrostomy, was observed with a soft wrist restraint on the left wrist, tied to the bed. The restraint was intended to prevent the resident from pulling at lines, tubes, and dressings. However, there was no documented informed consent from the resident or their representative for the use of this restraint. During interviews and record reviews, the Neuro Care Unit Manager acknowledged that the facility's policy, which requires informed consent for the use of physical restraints, was not followed. The policy mandates that the physician discuss the risks and benefits of restraint use with the resident or their representative and obtain informed consent. The failure to adhere to this policy resulted in the resident and their representative not being fully informed about the care and treatment provided.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to administer enteral nutrition as ordered for a resident, leading to a deficiency. The resident, who was admitted with a gastrostomy, heart failure, and tracheostomy, was supposed to receive a specific amount of tube feeding at a rate of 52 ml per hour until a total of 1040 ml was infused daily. However, during an observation, it was found that the feeding pump was still running and had infused a total of 1512 ml, exceeding the prescribed amount by 472 ml. This discrepancy was confirmed by a Licensed Vocational Nurse who acknowledged that the feeding pump should have been stopped according to the physician's order. The facility's policy and procedure for administering formula, which requires accurate administration as per the physician's order, was not followed. The Neuro Care Unit Manager confirmed that the policy was not adhered to and emphasized the importance of following the prescribed feeding amounts, as they are calculated based on the resident's nutritional needs. This failure to follow the policy and physician's order had the potential to increase the risk of aspiration and compromise the resident's health.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the secure storage of medications when a licensed nurse left Medication Cart #1 unlocked and unattended in the North wing. This incident was observed during a survey on August 15, 2024, at 5:33 AM, when a Licensed Vocational Nurse (LVN 6) was seen using the medication cart before entering a resident's room. The nurse did not lock the cart after removing the medication, leaving it vulnerable to unauthorized access. During an interview shortly after the observation, LVN 6 admitted to not locking the cart and acknowledged the importance of securing medications as per the facility's policy. A review of the facility's Policy and Procedure on Safe Storage of Medication, dated June 1974, confirmed that medication carts must be locked unless under direct supervision. The NeuroCare Unit Manager confirmed that the policy was not followed, emphasizing the necessity of keeping medications locked to ensure they are only accessible to authorized personnel.
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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 Convalescent Center Of San Bernardino | 0 mi | ★★★★★ | 0 | 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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