Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Shandin Hills Behavior Therapy Center during CMS and state inspections, most recent first.
Unclean kitchen and improper food storage: A turkey product in the refrigerator was not tightly covered and had liquid in the tray, an open box of fish filet had an unsealed inner bag, and an open box of frozen cookie dough had exposed dough with no open date. Kitchen ovens, drip trays, and cooking surfaces had heavy grease, carbonized residue, and dark buildup, and the emergency food storage room had dust, debris, and dry leaves on the floor and shelving. The AM and Admin confirmed the facility’s food storage and cleaning policies were not followed.
Unsecured Keys Left at Main Entrance Gate: Surveyors found multiple keys that opened the main locked gate and doors hanging on the outside gate with no staff present. An LVN initially could not locate her keys and then went to the gate to look for them, where the surveyor returned the keys to her. The Admin acknowledged the facility policy required exterior doors to remain secured and stated the keys should not have been left on the gate.
A recycling dumpster in the front area was observed overflowing with cardboard and debris, preventing the lid from fully closing, with staining on the exterior and debris on the surrounding ground. The AM confirmed the condition, and the Admin stated the lid should remain closed and the area maintained to prevent pest attraction. Facility policy and FDA Food Code required outside refuse and recycling containers to be kept closed and free of surrounding litter.
Resident bedrooms in Unit 2 did not meet the required square footage per resident in multiple-occupancy rooms. Measurements of 13 rooms showed that two-, three-, and four-bed rooms provided only about 58.3 to 73 square feet per resident, below the facility policy requirement of 80 square feet in double rooms and 100 square feet in single rooms. The MDIR confirmed the measurements, and the Admin acknowledged the policy requirements were not followed.
A resident was injured by another resident during a crowded medication line incident, where approximately 10 to 15 residents were present instead of the recommended 4 to 5. Both residents involved have schizophrenia and cognitive intactness. The facility lacked a specific policy on managing the number of residents in the medication line, which may have contributed to the altercation.
A resident with schizophrenia and a history of elopement left the facility unnoticed due to a faulty back door and inadequate supervision. The resident was missing for 15 hours before being returned by police. Staff were aware of the door issue, but it was not fixed in time to prevent the incident.
The facility did not follow the approved menu for lunch, serving a mixture of lettuce, tomato, and cheese with incorrect portion sizes, potentially compromising the nutritional status of 78 medically compromised residents. Observations showed dietary staff using a #24 scoop instead of the specified portions, and the Registered Dietician confirmed the need to adhere to the menu diet guide.
The facility failed to deliver mail to residents on Saturdays, affecting their communication rights. Three residents with conditions such as schizophrenia and nicotine dependence reported not receiving mail on weekends. The Social Services Director confirmed the lack of weekend mail distribution, despite facility policy requiring timely delivery. The Administrator acknowledged the issue, emphasizing the importance of residents' rights to receive mail.
A resident with a history of choking and medical conditions was not provided with the prescribed dysphagia mechanical soft diet on two occasions. The resident received regular food items instead of the required pureed and ground textures, as confirmed by observations and the facility's diet guide. The dietary aide admitted to the oversight, and the registered dietician emphasized the need to follow the diet guide.
A resident with schizoaffective disorder and other medical conditions was denied ketchup for his meal, despite his preference and no dietary restrictions against it. The facility's policy to honor individual dining preferences was not followed, leading to a deficiency in care.
The facility failed to maintain sanitary conditions in food preparation and storage areas. Observations revealed food crumbs and stains in plastic drawers, black sludge under sinks, and old meat on a slicer. Steam tables had grease and grime, and a dresser used for food storage was damaged and dirty. A plumbing repair left a rough wall patch. The facility's policies and FDA guidelines require cleanliness to prevent microorganism growth and pest attraction.
The facility failed to meet the required minimum of 80 square feet of livable space per resident in 13 rooms, affecting 29 residents. Despite the deficiency, the Administrator noted no complaints from residents, and the rooms appeared spacious and safe. A room waiver request was recommended by the survey team.
Unclean kitchen and improper food storage
Penalty
Summary
The facility failed to maintain a sanitary kitchen and food storage environment in accordance with professional standards for food safety. During observation, a turkey meat product wrapped in foil was found in the walk-in refrigerator inside a tray with the wrapping not tightly sealed and with yellow-dark liquid accumulation in the tray. In the freezer, an open box of fish filet had an inner plastic bag that was not properly sealed, and an open box of frozen chocolate chip cookie dough had an inner clear plastic bag left open with the dough exposed and no date indicating when the bag was opened. The Account Manager confirmed the food items were not stored as required. The kitchen equipment was also observed with heavy grease, carbonized food residue, burnt buildup, and visible grease accumulation on cooking surfaces, ovens, drip trays, oven door edges, exterior surfaces, interior walls, and bottom trays. Dark buildup and debris were present on the oven door pane and lower oven trays, including heavier accumulation in the left lower oven. The Account Manager acknowledged the equipment should be clean and stated the facility policy requiring food contact surfaces and cooking equipment to be cleaned and sanitized after each use was not followed. The emergency food storage room was observed unclean, with dust accumulation on the floor, shelving, and water containers, along with dry leaves and debris scattered on the floor. The Admin stated the facility did not have an established cleaning schedule for the emergency supplies room and that the last cleaning occurred in December 2025. The facility policy for dry goods storage required items to be kept clean, dry, properly sealed, and stored in accordance with the FDA Food Code, and the Account Manager confirmed that this policy was not followed.
Unsecured Keys Left at Main Entrance Gate
Penalty
Summary
The facility failed to ensure a secure environment when multiple keys that opened the main locked gate and doors to the facility were left hanging on the outside gate. During an observation, surveyors found the keys on the outside of the main entrance gate with no staff at the gate. After entering through the main entrance door and a second door that led directly to the resident dining room, surveyors observed the unsecured access point into the building. During interview, an LVN stated the main entrance door should be locked at all times and initially could not locate her keys, then walked to the main gate to look for them. The surveyor informed her the keys were at the gate and returned them to her. The Administrator reviewed the facility policy on Facility Security and Locked Door, which stated exterior doors remain secured, and acknowledged the keys should not have been left on the gate. The LVN later stated she should not have left the keys there and acknowledged the risk that unwanted visitors could enter the building and resident safety could be compromised.
Overflowing Recycling Dumpster With Debris and Staining
Penalty
Summary
Improper disposal of garbage and refuse was identified when the recycling dumpster in the front area of the building was observed overflowing with cardboard and debris, which prevented the lid from fully closing. The exterior surfaces of the dumpster had visible staining and buildup, and debris was present on the surrounding ground area during the observation and interview with the Account Manager. During the interview, the Account Manager confirmed the condition and stated the lid should remain closed to prevent pest attraction. The Administrator later stated the lid should remain closed and the area maintained to prevent pest attraction. The facility policy required outside dumpsters to be kept closed and free of surrounding litter, and the FDA Food Code required refuse and recycling receptacles used outside the food establishment to have tight-fitting lids, doors, or covers.
Resident Bedrooms Did Not Meet Required Square Footage
Penalty
Summary
Resident bedrooms in Unit 2 failed to provide the minimum square footage required per resident in multiple-occupancy rooms. Based on observation, interview, and measurement, 13 of 13 resident rooms reviewed, Rooms 30 through 42, did not meet the required 80 square feet per resident for double or multiple resident rooms. The rooms measured included two-bed, three-bed, and four-bed rooms, with total livable space ranging from 119 square feet to 233 square feet, resulting in approximately 58.3 to 73 square feet per resident in the rooms measured. During the measurement process, the rooms were observed in the presence of the Maintenance Director, and the residents occupying the rooms were seen using the available space without immediate safety concerns. The Maintenance Director confirmed the measurements and stated that no additions or structural changes had been made to increase the size of the resident rooms in Unit 2. The Administrator later reviewed the facility policy titled Bedrooms, which required at least 80 square feet of usable living space per resident in double rooms and at least 100 square feet in single rooms, and confirmed that the policy requirements were not followed.
Resident-to-Resident Altercation Due to Overcrowded Medication Line
Penalty
Summary
The facility failed to protect a resident from abuse by another resident during a medication line incident. Resident 1 was struck by Resident 2 while waiting in line for medication, resulting in physical injuries including a scratch below the left eyebrow, a bruise on the left forehead, and a scratch on the left arm. The incident occurred in a crowded hallway where approximately 10 to 15 residents were present, exceeding the recommended number of 4 to 5 residents waiting at a time. Resident 1, who has a diagnosis of schizophrenia and a BIMS score indicating cognitive intactness, reported being punched by Resident 2 without provocation. Resident 2, also diagnosed with schizophrenia and having a similar BIMS score, was identified as having a care plan for aggressive behavior. Despite this, Resident 2 approached and struck Resident 1 multiple times, causing Resident 1 to fall and spill water. Staff intervened by calling a code and verbally redirecting Resident 2, who then ceased the behavior and walked away. Interviews with staff and other residents confirmed the overcrowding in the medication line, which may have contributed to the incident. The Program Director acknowledged the lack of a specific policy and procedure regarding the number of residents allowed in the medication line at one time. The facility's existing policy on resident-to-resident altercations requires staff to monitor for aggressive behaviors, but the absence of a clear guideline on managing the medication line may have exacerbated the situation.
Resident Elopement Due to Faulty Door and Inadequate Supervision
Penalty
Summary
The facility failed to implement adequate monitoring and supervision for a resident with a history of elopement. The resident, who was admitted with schizophrenia, left the facility without staff awareness when the back door was unlocked. The resident was missing for 15 hours before being returned by the police. The resident's elopement was facilitated by a faulty back door that did not lock properly, allowing the resident to exit the premises unnoticed. Interviews and record reviews revealed that the resident had a history of elopement, as indicated in their Elopement Evaluation. On the day of the incident, the resident took advantage of the situation when a Certified Nurse Assistant went on break, leaving only one staff member at the nurse's station. The resident was able to open the malfunctioning door and scale a fence to leave the facility. The resident then traveled to another city, where they interacted with substances that could have adverse effects when combined with their prescribed medications. Staff interviews confirmed that the back door was known to be faulty, and the Maintenance Supervisor was informed of the issue on the morning of the elopement. However, the door was not repaired in time to prevent the resident's departure. The facility's policy required continuous supervision and monitoring of residents at risk for elopement, but this was not adequately implemented, leading to the resident's unsupervised exit.
Failure to Follow Approved Menu Portions
Penalty
Summary
The facility failed to adhere to their approved menu for lunch on November 12, 2024, when Dietary staff served a mixture of lettuce, tomato, and cheese using a #24 scoop, which is equivalent to 1.33 ounces or 2-2/3 tablespoons, instead of the specified 1/4 cup (4 tablespoons) of shredded lettuce and diced tomato topping and 1 tablespoon of shredded cheddar cheese. This deviation from the menu had the potential to compromise the nutritional status of 78 medically compromised residents who received food from the kitchen. Observations during the tray line on November 12, 2024, revealed that the dietary staff in both Unit 1 and Unit 2 used the incorrect scoop size for serving the lettuce, tomato, and cheese mixture. The facility's Diet Guide Sheet, dated the same day, specified the correct portion sizes for the meal components. An interview with the Registered Dietician confirmed that the recipe and menu diet guide should be followed. The facility's policy and procedure on menus, dated September 2017, stated that menus should be served as written unless a substitution is necessary due to preference, unavailability, or a special meal requirement.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents had reasonable access to their mail on Saturdays, which is a violation of their rights to communication. This deficiency affected three residents, who were identified as having diagnoses including schizophrenia and nicotine dependence. These residents reported during a Resident Council meeting that they did not receive mail on Saturdays, only from Monday to Friday. The Social Services Director confirmed that there was no staff available to distribute mail on weekends, despite the facility's policy requiring mail to be delivered within twenty-four hours of delivery, including Saturdays. The facility's policy, titled 'Mail and Electronic Communication,' was not adhered to, as the mail delivered on Saturdays was not distributed until the following Monday. The Social Services Director acknowledged the oversight and mentioned that the facility was working on obtaining an additional key to access the mailbox on weekends. The Administrator also confirmed that the Social Services Director was responsible for mail delivery and emphasized the importance of residents receiving their mail on Saturdays as part of their rights.
Failure to Provide Prescribed Dysphagia Diet
Penalty
Summary
The facility failed to provide a dysphagia mechanical soft diet as prescribed for a resident, leading to the resident receiving inappropriate food textures on two separate occasions. On November 12, 2024, the resident was served a regular diet consisting of regular beef tacos and green chili rice instead of the prescribed pureed tortilla and pureed green chili rice. The following day, November 13, 2024, the resident received chopped pork and a slice of bread instead of the prescribed ground roast pork and pureed bread. These deviations from the prescribed diet were observed during meal service and confirmed through a review of the facility's menu diet guide. The resident involved had a history of paranoid schizophrenia, diabetes mellitus, and hyperlipidemia, and had experienced a choking episode on September 2, 2024, which led to the modification of her diet to a dysphagia mechanical soft texture. The dietary aide responsible for preparing the meals admitted to forgetting to puree the tortilla, rice, and bread, and the registered dietician confirmed that meals should adhere to the diet guide. The facility's Diet and Nutrition Care Manual specifies that the dysphagia mechanically altered diet should include cohesive, moist, semi-solid foods that require some chewing ability, and excludes most bread products and other dry foods.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 278, when he requested ketchup for his lunch on November 12, 2024, and was denied by a dietary staff member. The staff member's refusal was based on the absence of fries in the meal, despite the resident's expressed preference for ketchup to add flavor to his meals. This incident was observed during a lunch service and was later corroborated by interviews with the Program Director and Registered Dietician, both of whom confirmed that there were no dietary restrictions preventing the resident from having ketchup. Resident 278, who has a medical history including schizoaffective disorder, enlarged lymph nodes, and nicotine dependence, was noted to have a care plan that included honoring his food preferences within his meal plan. Despite this, the facility's policy on dining and food preferences, which emphasizes the identification and accommodation of individual preferences, was not adhered to in this instance. The resident expressed a preference for condiments like ketchup, salt, pepper, and sugar to enhance the flavor of his meals, which was not accommodated, leading to the deficiency noted in the report.
Unsanitary Food Preparation and Storage Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices, as observed during a survey. There were multiple instances of unsanitary conditions in the kitchen and dining areas. Two plastic drawers under the coffee maker were found with food crumbs and spill stains, and the base and shelf they were on also had a buildup of food crumbs. The Dietary Manager Consultant acknowledged the need for cleaning, and the Registered Dietitian stated that surfaces should be maintained clean. Additionally, a black sludge-like buildup was found under the three-compartment sink, which the RD stated should be cleaned daily. The meat slicer in the facility had old meat crusted on the blade, which the Dietary Manager acknowledged. The RD emphasized that the slicer should be cleaned and sanitized after every use. Furthermore, the steam tables in the dining rooms of units one and two were found with grease, grime, and food crumbs, with a rust-like substance on the stainless-steel shelf. The RD stated that these steam tables should be cleaned daily. A dresser used to store condiments and food next to the steam table in unit two had a buildup of crumbs and stains, with water damage and warping on the drawers. A plumbing repair under the dishwasher left a wall patch that was rough and not smooth or painted, with visible mesh and incomplete spackle coverage. The RD stated that nothing should be falling off or peeling from the patch. The facility's policy and procedure, as well as the FDA Federal Food Code, require that all food preparation and service areas be maintained in a clean and sanitary condition, with nonfood-contact surfaces kept free of dust, dirt, food residue, and other debris to prevent microorganism growth and pest attraction.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet of livable space per resident in 13 rooms, affecting 29 residents. During an observation and interview with the Facility Maintenance Director, it was found that the rooms measured less than the required space, with some rooms providing as little as 58.5 square feet per resident. The specific measurements for each room were documented, revealing that none of the rooms met the regulatory requirements for space per resident. Despite the deficiency in room size, the Administrator acknowledged awareness of the measurements and noted that there were no complaints from residents regarding space or room issues. The residents were reportedly able to walk around safely, and the rooms appeared spacious and not crowded, posing no immediate safety hazards. The survey team recommended the approval of a room waiver request for the rooms listed in the deficiency.
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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) |
|---|---|---|---|---|
| Hillcrest Nursing Home | 0.2 mi | ★★★★★ | 6 | 0 |
| Arrowhead Healthcare Center, Llc | 1.2 mi | ★★★★★ | 11 | 0 |
| Waterman Canyon Post Acute | 3.2 mi | ★★★★★ | 2 | 0 |
| Community Convalescent Center Of San Bernardino | 3.3 mi | ★★★★★ | 0 | 0 |
| Community Hospital Of San Bernardino Dp Snf | 3.3 mi | ★★★★★ | 19 | 0 |
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