Community Convalescent Center of San Bernardino

In the surveyor’s words

From the most serious findings on record at Community Convalescent Center of San Bernardino, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jul 24, 2026

  1. Based on observation, interview, and record review, the facility failed to ensure staff followed accepted infection control practices, including required hand hygiene and glove changes between distinct care tasks, during gastrostomy tube (GT - a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) site treatment and medication administration for one (1) of four sampled residents (Resident 8). This failure had the potential to expose Resident 8 at risk for contamination of the GT tract and potential introduction of pathogens during medication administration, increasing the risk for avoidable infection, unnecessary treatment and possible hospitalization. 2. […]

• No harm, potential for more than minimal, widespreadF880Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when: 1. An action plan was not initiated in a timely manner following a positive water test for Legionella (a bacteria that grows in water systems such as air conditioners or hot water tanks and can cause a lung infection) performed on February 4, 2025. 2. An open enteral feeding system (a feeding bag filled with formula that delivers liquid nutrition through a tube to a resident's stomach) was not labeled correctly with the date and time for Resident 7. 3. […]

• No harm, potential for more than minimal, widespreadF880Apr 17, 2024

  Based on interviews and facility policy review, the facility failed to have evidence of the implementation of their water management program. This deficient practice affected all 18 residents who currently resided in the facility. Findings included: A review of the facility policy titled, Utility Water Safety Management, last reviewed in February 2024, revealed, Background: Legionnaires' disease is a serious type of pneumonia caused by bacteria, called Legionella, that live in water. Legionella can make people sick when they inhale contaminated water from building water systems that are not adequately maintained. Purpose The purpose of this management program is to reduce the risk for Legionnaires' disease associated with facility water systems and devices. […]

• No harm, potential for more than minimal, widespreadF726Oct 20, 2022

  Based on interviews, and record review, the facility failed to have a Director of Staff Development (DSD - Orient and educate nursing staff to ensure safe and effective nursing care according to federal, state and facility guidelines) available in the facility to provide ongoing education and evaluation of competencies. These failures had the potential to result in inappropriate care and services for 29 residents residing in the facility. Findings: During an interview on October 20, 2022, at 4:07 PM, with a License Vocational Nurse (LVN 6), LVN 6 stated she completed her annual competencies (application and demonstration of appropriate skills, knowledge and abilities in a clinical setting), at an offsite facility (the general acute care hospital's Education Department). […]

• No harm, potential for more than minimal, patternF812Jul 24, 2026

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as required when:1. One refrigerator and one freezer were observed without temperature monitoring to ensure food was held at safe temperatures.2. The automatic paper towel dispenser at the handwashing sink in the kitchen was not functioning.3. The microwave contained food splashes.4. The middle basin of the three compartment sink contained old food residue, and the countertop had powder residue.5. Seven of eight frozen meals stored in the freezer were expired.6. During lunch tray line assembly, one nutrition aide in the main kitchen did not wash her hands between glove changes.7. […]