Community Convalescent Center of San Bernardino

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement their policy and procedure (P&P) on antibiotic stewardship (a set of practices aimed at ensuring the safe and effective use of antibiotics [medications used to treat infections]) for one of six sampled residents (Resident 167) reviewed for antibiotic used when the Infection Control Preventionist (ICP) nurse did not accurately analyze the collected data to identify purpose of the antibiotic use to indicate the rationale and common clinical conditions necessary to ensure the appropriate use of antibiotic therapy for Resident 167. This failure had the potential to place Resident 167 at risk for adverse events, including the development of anti-biotic resistant organisms, from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage of medications when seven packets of protein supplement (a nutritional supplement given to support dietary needs) were expired and available for resident use. This failure had the potential to affect the health and safety of 15 medically compromised residents placing them at risk for infection and at risk of administering a supplement with decreased potency, that may not achieve desired effect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent cross contamination from a Certified Nursing Assistant 1 (CNA 1) when CNA 1 did not wash her hands prior to handling a meal tray, and removed food from the tray to heat in the microwave with her bare hands. Furthermore, CNA 1 did not heat the food to the correct temperature. These failures put Resident 10, who was already medically compromised, at risk for food-borne illness (caused by eating or drinking something that is contaminated with bacteria, viruses, or parasites, that can make people sick).

Inspectors wroteBased on interview and record review, the facility failed to protect against physical abuse for one of three sampled residents (Resident 1) when Resident 1 was slapped on the hand by a School Licensed Vocational Nurse (S/LVN). This failure caused Resident 1 to suffer abuse and fear.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote2. During an observation on October 19, 2022, at 5:30 AM, a Licensed Vocational Nurse (LVN 1) walked away from Medication Cart 1 without locking and securing the cart. No other licensed nurse were observed in the hallway. During an interview on October 19, 2022, at 5:40 AM, with LVN 1, LVN 1 confirmed she left the medication cart unlocked and stated she went down the hall and forgot to lock it. LVN 1 opened the drawers of the medication cart and verified it contained 12 drawers with medications in them, for six different residents. LVN 1 further stated the medication cart should have been locked. During a concurrent interview and record review with the Pharmacy Manager (PM), on October 19, 2022, at 1:30 PM, the facility's policy and procedure (P&P) titled, Safe Storage of Medications, dated February 2020, was reviewed. The P&P indicated, . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Resident 28's enteral feeding (Nutrition delivered directly into gastrointestinal tract) administration set was not covered with a protective endcap when it was not in use. 2. Two visitors (Visitor 1 and 2) did not wear a mask and did not perform COVID-19 (a highly contagious illness caused by a virus) screening upon entry into the facility on October 20, 2022, in accordance with the facility's policy and procedure. 3. Resident 4's enteral feeding administration set was not covered with a protective endcap when it was not in use. 4. Resident 21's enteral feeding administration set was not covered with a protective endcap when it was not in use. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a nutritional assessment was completed upon admission for one of three residents (Resident 25) reviewed for nutrition. This failure had the potential to place Resident 25 at risk of weight loss and dehydration (condition caused by the loss of too much fluid from the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff followed physician's orders for flushing (to clear by using a prescribed amount of water) G-tube (gastrostomy tube-a tube inserted through the belly that brings nutrition or medications directly to the stomach) lines before, after and in-between medication administration for two of 14 residents (Residents 21 and 29). This failure had the potential to cause an interaction to occur between medications resulting in a reduced drug effect, or drug toxicity, as well as clogging the G-tube.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff wasted (disposed of) controlled drugs (any drug or therapeutic agent-commonly understood to include narcotics, with a potential for abuse or addiction, which is held under strict governmental control) in accordance with the facility's policy and procedure titled, Controlled Substance Waste, dated reviewed February 2020, for 29 residents. This failure had the potential to cause drug diversion (the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) and accidental exposure.