Community Hospital Of San Bernardino D/P SNF

In the surveyor’s words

From the most serious findings on record at Community Hospital Of San Bernardino D/P SNF, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 20, 2025

  Based on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 1) was safely reconnected to the ventilator (a machine that supports or controls a person's breathing when they cannot breathe adequately on their own) following a shower. This failure resulted in an avoidable interruption in Resident 1's life supporting respiratory assistance and requiring a code blue response (an emergency code indicating a patient needs immediate medical attention), which had the potential to cause brain damage from lack of oxygen, and lead up to death. […]

• Actual harm, isolatedF689Oct 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents are free of accidents for one of three residents (Resident 1) when Licensed Vocational Nurse (LVN 1) and Certified Nursing Assistant (CNA 1) did not ensure the attachment holding the bar and scale of the Hoyer lift (a mechanical device used to transfer people from one surface to another) was properly secure prior to Resident 1's transfer. This failure resulted in the attachment holding the bar and scale of the Hoyer lift became disconnected which caused Resident 1 falling from the Hoyer lift, sustaining a head laceration (cut), and requiring suture and closed observation in the Intensive Care Unit (ICU).Findings: A review of Resident 1's face sheet (contains demographic and medical information),… […]

• Actual harm, isolatedF689Sep 7, 2022

  Based on observation, interview, and record review, the facility failed to ensure the nursing staff were trained to use transfer equipment properly in accordance with the manufacturer's recommendations and followed a safe lifting technique during a sling scale lift (SSL- a mechanical device used to assist residents and staff during transfers) for one out of three sampled residents (Resident 1) on August 9, 2022. This failure resulted in Resident 1's falling, sustaining a laceration (a deep cut or tear in the skin) on the back of her head, and scalp. Resident 1 was required to be transferred to the general acute care hospital (GACH). […]

• No harm, potential for more than minimal, widespreadF880Sep 3, 2026

  Based on observation, interview, and record review, the facility failed to ensure staff followed safe infection control practices when: 1. One Licensed Vocational Nurse (LVN 3) dropped a Multivitamin/Multimineral Liquid Supplement (a multidose bottle, containing drinkable mix of vitamins and minerals that helps people get important nutrients when they don't get enough from food) lid on the floor, attached the lid back on to the multidose bottle, and returned the medication bottle to the medication cart. 2. […]

• No harm, potential for more than minimal, widespreadF880Aug 27, 2025

  Based on observation, interview, and record review the facility failed to maintain an infection control program for 14 of 85 sampled residents (Resident 16, 18, 22, 24, 33, 41, 43, 52, 63, 68, 77, 82 and 83) when: 1. For one resident (Resident 41), there was no date or staff initial on Resident 41's gastro enteral tube (G tube- a feeding tube inserted through abdomen into the stomach to provide nutrition, fluids, and medication directly to the digestive system) and water flush bag (a bag with water administered to residents through G tube). 2. […]