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 Haven Post Acute during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and moderate cognitive impairment, admitted with a healing fracture, reported a fall after an RN responded to a scream and found the resident in bed. The RN assessed the resident, found no injuries, but did not document the resident’s report of a fall or the assessment. Subsequent review by LVNs and the DON confirmed there was no record of the incident, despite facility policy requiring documentation of all incidents, changes in condition, and events in the medical record.
The facility failed to maintain cleanliness in the kitchen's walk-in refrigerator, as grime and debris were found on the floors and walls during an inspection. The Dietary Supervisor acknowledged the issue, and the Administrator confirmed that staff did not follow the facility's sanitation policies. The US FDA Federal Food Code requires equipment and surfaces to be clean to prevent pathogenic microorganisms and pests.
A resident experienced significant weight loss, but the facility failed to implement the RDN's recommendations for weekly weight monitoring and an appetite stimulant. The resident's weight was not consistently recorded, and the appetite stimulant was delayed by 79 days. The DON cited communication breakdown as the cause of these failures.
The facility failed to properly store and label medications and treatment supplies, as evidenced by expired central line trays and dressings found in carts, and an unidentified cream under a resident's bed. The DON confirmed that facility policies were not followed, posing potential health risks to residents.
A resident with a fractured hip and severe pain did not receive prescribed Norco for pain management, despite reporting a pain level of 8/10. The LVN failed to administer the medication as ordered, and the DON confirmed the facility's policy was not followed, leading to a deficiency in pain management.
A resident experienced severe pain and elevated blood sugar due to medication administration errors, resulting in a 9.09% error rate. The errors included late administration of diabetes medications and failure to provide pain relief as ordered. The facility's policy of timely medication administration was not followed, contributing to the deficiency.
A resident in an LTC facility did not receive their prescribed medications on time, leading to a significant medication error. The resident, with a history of diabetes and severe pain, received their diabetes medications late and did not receive the prescribed pain medication. The facility's policy of administering medications within one hour of the prescribed time was not followed, as confirmed by the LVN and DON.
The facility failed to follow its policy to ensure call lights are answered in a timely manner for four residents. One resident reported wait times up to two hours, another experienced delays ranging from 15 minutes to 15 hours, a third had a three-hour delay requiring her husband's intervention, and a fourth also noted slow responses. The facility's policy requires calls to be answered within 5 minutes, but this was not adhered to, compromising resident safety.
A resident with schizoaffective disorder, altered mental status, and toxic encephalopathy, assessed as having a moderate risk of elopement, was able to leave the facility unsupervised and remained missing for over 72 hours. The resident's care plan did not specify the necessary monitoring needs and frequency. Staff members, including a CNA and an LVN, failed to adequately monitor and report the resident's absence, contributing to the incident. The facility's policies and procedures were not effectively followed, resulting in insufficient supervision and documentation.
Failure to Document Resident-Reported Fall and Assessment
Penalty
Summary
The facility failed to maintain complete and accurate medical records by not documenting a resident-reported fall and subsequent nursing assessment. A resident with Alzheimer’s disease and a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment, had been admitted with diagnoses including a subsequent encounter for fracture. On the date of the incident, an RN responded to a scream from the resident’s room and found the resident in bed, who stated she had fallen. The RN reported that the resident appeared disoriented and was unable to provide further details about the alleged fall. The RN stated she conducted a thorough assessment of the resident’s body and found no signs of injury, but she did not document the resident’s report of a fall or the assessment in the medical record. During later review of the clinical record by two LVNs and the DON, no documentation of the reported fall or related assessment could be found. The DON and RN both acknowledged that facility policy requires documentation of all incidents, changes in condition, and events involving the resident, and that this documentation was not completed. As a result, the medical record did not reflect the resident’s reported change in condition as required by the facility’s charting and documentation policy.
Failure to Maintain Cleanliness in Kitchen's Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain the cleanliness of the kitchen's walk-in refrigerator, as observed during a survey. On March 3, 2025, during an inspection with the Dietary Supervisor, grime and debris were found on the floors and walls of the walk-in refrigerator, particularly underneath the shelve racks. The Dietary Supervisor acknowledged the issue and stated that the condition was unacceptable, emphasizing that the refrigerator should be free of grime and debris. Further review of the facility's policy and procedure on sanitation, revised in 2023, revealed that all utensils, counters, shelves, and equipment should be kept clean and free from breaks, corrosion, and debris. The Administrator confirmed that the facility staff did not adhere to these policies, acknowledging that the kitchen, including the walk-in refrigerator, should be clean. The US FDA Federal Food Code was also reviewed, which mandates that equipment and surfaces be clean to sight and touch to prevent the accumulation of pathogenic microorganisms and the attraction of insects or rodents.
Failure to Implement Weight Change Protocol for Resident
Penalty
Summary
The facility failed to implement the weight change protocol for a resident, identified as Resident 50, who was at nutritional risk. The Registered Dietitian Nutritionist (RDN) had recommended weekly weight monitoring and the administration of an appetite stimulant due to the resident's significant weight loss. However, these recommendations were not carried out in a timely manner. Specifically, the resident's weekly weights were not consistently recorded during September and November 2024, and the appetite stimulant was not ordered until January 2025, despite being recommended in November 2024. Resident 50 was admitted with diagnoses including acute kidney failure, dysphagia, and depression, and was identified as having a poor appetite. The resident experienced a weight loss of 14 pounds over 38 days and a further loss of 15 pounds by November 2024. Despite these significant weight changes, the facility did not follow the RDN's recommendations for weekly weight monitoring and the timely administration of an appetite stimulant, which was delayed by 79 days. The Director of Nurses (DON) acknowledged the failure to implement the RDN's recommendations, attributing it to a breakdown in communication and an oversight due to an email miscommunication. The facility's policy on weight change protocol, which requires timely assessment and intervention for residents experiencing significant weight changes, was not adhered to in this case.
Improper Storage and Labeling of Medications and Supplies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and treatment supplies, as evidenced by several observations. Two expired central line trays were found in the intravenous cart, which were validated by a Registered Nurse (RN) as being expired for four months. The Director of Nursing (DON) confirmed that the facility's policy and procedure regarding the labeling of medication containers was not followed. Additionally, six different types of expired dressings were discovered in the treatment cart, with expiration dates ranging from two to 22 months past due. The Treatment Licensed Vocational Nurse (Tx LVN) acknowledged the expired status of these dressings and confirmed they should not have been available for use. Furthermore, a medication treatment cup filled with an unidentified cream was found underneath a resident's bed, which was verified by a Licensed Vocational Nurse (LVN) as improperly stored. The DON stated that medications should be stored safely and not be easily accessible to residents. The facility's policy on the storage of medications, which requires drugs and biologicals to be stored in locked compartments, was not adhered to. These lapses in following established policies and procedures had the potential to compromise the sterility and effectiveness of medical supplies, posing a risk to the health of the facility's residents.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to implement its Pain Assessment and Management policy for a resident who required pain management services. Resident 214, who was admitted with a displaced intertrochanter fracture of the left femur, hypertension, and type 2 diabetes mellitus, had a physician's order for Pregabalin and Hydrocodone-Acetaminophen (Norco) for pain management. On March 4, 2025, the resident reported severe pain with a pain scale of 7/10 and later 8/10, yet the Norco was not administered as ordered by the physician. During an observation, the resident was found in bed, experiencing severe pain, and had not received the prescribed Norco. The LVN acknowledged the oversight and confirmed that the Norco should have been administered. The Director of Nurses reviewed the facility's medication administration policy, which mandates that medications be administered in a safe and timely manner as prescribed. The policy was not followed, as there was no requirement for Norco and Pregabalin to be given separately or one hour apart, leading to the deficiency.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 9.09% error rate during a medication administration observation. This was due to three medication errors out of 33 opportunities, specifically affecting one resident, Resident 214. The errors involved the late administration of Metformin HCL and Glipizide ER, which were given one hour and forty-two minutes after the scheduled time, and the failure to administer Norco for pain management as ordered by the physician. Resident 214, who was admitted with a displaced intertrochanter fracture of the left femur, hypertension, and type 2 diabetes mellitus, experienced severe pain and elevated blood sugar levels due to these medication errors. The resident reported a pain level of 8/10 and had a blood sugar reading of 251 mg/dL. The facility's Director of Nurses acknowledged that the staff did not follow the policy of administering medications within one hour of the prescribed time, which contributed to the deficiency.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a survey. The resident, who was admitted with a displaced intertrochanter fracture of the left femur, hypertension, and type 2 diabetes mellitus, did not receive their prescribed medications in accordance with the physician's orders and facility policy. On the morning of March 4, 2025, the resident's Metformin and Glipizide, which were scheduled for 8:00 AM, were administered one hour and forty-two minutes late. Additionally, the resident, who reported severe pain, did not receive the prescribed Norco for pain management. The delay in administering the diabetes medications was acknowledged by the LVN and the Director of Nurses (DON) as not being in compliance with the physician's orders. The facility's policy required medications to be administered within one hour of their prescribed time, which was not adhered to in this case. The DON confirmed that the Metformin was intended to be given with breakfast to effectively regulate blood sugar levels, and the failure to administer Norco for the resident's reported pain was also not in compliance with the physician's orders.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for four sampled residents. Resident 1 expressed dissatisfaction with the night shift response to call lights, noting occasional wait times extending up to two hours. Resident 2 reported that staff members took an extended period, ranging from 15 minutes to 15 hours, to respond to call lights, resulting in instances where the resident was left unattended and soiled. Resident 3 reported extended wait times over an hour or more, with one instance of a three-hour delay requiring intervention by her husband. Resident 4 also stated that staff did not respond to call lights on time. These observations were confirmed through interviews and record reviews, indicating a consistent issue with call light response times across multiple residents. The facility's policy titled 'Call System, Resident' indicated that calls for assistance should be answered as soon as possible, but no later than 5 minutes, with urgent requests addressed immediately. However, the facility failed to adhere to this policy, as evidenced by the grievances and complaints from the residents. The Social Worker confirmed receiving a grievance from Resident 3, and staff were in-serviced about bedside manner. A review of the Resident Grievance/Complaint Investigation Report indicated that a grievance was reported regarding a Certified Nurse Assistant's bedside manner, and the Director of Staff Development was informed about the grievance. Despite these measures, the facility's failure to respond promptly to call lights jeopardized the health and safety of the residents involved.
Inadequate Supervision Leading to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a resident (Resident 1) identified as having a moderate risk of elopement. Resident 1 had a history of schizoaffective disorder, altered mental status, and toxic encephalopathy, which impacted his decision-making capacity and cognitive abilities. Despite being assessed as at moderate risk for elopement, Resident 1's care plan did not address the specific monitoring needs and frequency required to prevent him from leaving the facility unsupervised. On March 6, 2024, Resident 1 was found to have eloped from the facility and had not been located for more than 72 hours, exposing him to risks such as exposure to the elements, missed medications, and potential medical complications. The deficiency in supervision was highlighted by the failure of staff members to adequately monitor Resident 1. Certified Nurse Assistant 1 (CNA 1) failed to report to the Licensed Vocational Nurse (LVN 1) that Resident 1 was missing during lunchtime, assuming he was in the restroom without verifying his location. LVN 1 did not actively look for Resident 1 after realizing he had not eaten lunch and was missing. The facility's lack of adherence to its own policies and procedures, as outlined in job descriptions for nursing staff, contributed to the breakdown in supervision and monitoring of residents at risk of elopement. The facility's inadequate response to Resident 1's elopement, as evidenced by delays in recognizing his absence and initiating a search, further exacerbated the deficiency in supervision. Despite Resident 1's known risk factors and history of altered mental status and wandering behavior, the facility's staff did not implement the necessary precautions to ensure his safety. The lack of proper monitoring, failure to conduct regular checks on Resident 1's whereabouts, and insufficient documentation of supervision efforts all contributed to the deficiency in providing adequate supervision to prevent elopement incidents.
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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) |
|---|---|---|---|---|
| Del Rosa Villa | 0.8 mi | ★★★★★ | 14 | 0 |
| Waterman Canyon Post Acute | 1.3 mi | ★★★★★ | 2 | 0 |
| Valley Healthcare Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Medical Center Convalescent Hospital | 1.5 mi | ★★★★★ | 13 | 0 |
| Arrowhead Springs Healthcare | 1.6 mi | ★★★★★ | 0 | 0 |
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