SAN BERNARDINO, CA - Federal inspectors identified immediate jeopardy conditions at Valley Healthcare Center after discovering residents smoking unsupervised while possessing lighters and cigarettes, creating substantial fire hazards throughout the 86-bed facility during a March 2025 survey.
Immediate Jeopardy: Unsupervised Smoking Creates Fire Risk
The most serious violation discovered during the inspection involved the facility's smoking safety practices, which prompted regulators to issue an immediate jeopardy citation—the most severe finding possible in nursing home oversight. Inspectors found that smoking residents had unrestricted access to lighters and cigarettes and were smoking without staff supervision, creating conditions that could result in serious injury or death.
The facility failed to conduct proper smoking assessments on admission and quarterly thereafter, meaning staff had no systematic way to identify which residents smoked or to evaluate whether those residents could safely handle smoking materials. Without these assessments, the facility could not determine which residents had the cognitive ability and physical dexterity to smoke safely or which residents required supervision during smoking activities.
Additionally, the facility failed to develop individualized care plans addressing smoking activities for residents who smoked. Care plans serve as roadmaps for staff to provide appropriate care tailored to each resident's specific needs and abilities. Without these plans, staff had no guidance on how to safely manage smoking activities for individual residents.
Fire safety in nursing homes is particularly critical because many residents have limited mobility and cannot evacuate quickly in an emergency. Residents with cognitive impairments may not recognize fire dangers or respond appropriately to alarms. Smoking materials remain one of the leading causes of fatal fires in residential settings, and nursing homes must implement rigorous protocols to prevent fire-related injuries and deaths.
The facility implemented a corrective action plan on March 6, 2025, which included conducting thorough smoking assessments for all residents who smoke, implementing a new screening tool to evaluate safety and capability for smoking activities, securing all lighters in a locked box in the medication room, and requiring staff supervision during all smoking activities. The facility also updated admission procedures to include smoking assessments and revised medication administration records to help nurses monitor smoking residents. Staff received training on the facility's smoking policy and safety measures, and the facility implemented half-hourly monitoring of the designated smoking area with documentation logs.
After verifying implementation of these corrective measures through observation, interviews, and record review, regulators lifted the immediate jeopardy finding on March 6, 2025, at 4:15 p.m.
Oxygen Administration Failures Compromise Respiratory Care
Inspectors identified significant failures in respiratory care that affected two residents requiring supplemental oxygen therapy. During a facility tour on March 3, 2025, surveyors observed Resident 51 receiving oxygen through a nasal cannula at a flow rate of 1 liter per minute (LPM), when the physician had ordered 2 LPM. The Licensed Vocational Nurse confirmed the incorrect flow rate during an interview.
Resident 51 had been admitted in December 2024 with chronic obstructive pulmonary disease (COPD), a progressive lung condition that makes breathing difficult and requires carefully calibrated oxygen therapy. The resident had full cognitive capacity to make decisions but relied on staff to ensure medical equipment was set correctly according to physician orders.
Oxygen therapy dosing is not arbitrary—physicians prescribe specific flow rates based on individual patient needs, arterial blood gas measurements, and oxygen saturation levels. Receiving insufficient oxygen can lead to hypoxemia (low blood oxygen levels), which can cause confusion, rapid heart rate, shortness of breath, and in severe cases, organ damage or death. Conversely, excessive oxygen in COPD patients can suppress the respiratory drive, leading to carbon dioxide retention and respiratory failure.
The second oxygen-related violation involved Resident 67, who was observed using an oxygen concentrator at 5 LPM without any physician's order for oxygen therapy. Medical records staff confirmed no order existed for this treatment. Resident 67 had been admitted in December 2024 with acute respiratory failure with hypoxia—a serious condition indicating dangerously low tissue oxygen levels.
The facility did not obtain a physician's order for oxygen administration until March 4, 2025—more than two months after admission—when the physician ordered oxygen at 2-5 liters via nasal cannula as needed for shortness of breath, low oxygen saturation, and comfort. The charge nurse is responsible for carrying out physician orders, including oxygen administration, at the start of resident admission and for checking that oxygen equipment is set to the correct flow rate.
The facility's own policy on oxygen administration specified that staff should verify physician orders exist before administering oxygen and should start oxygen flow at 2 to 3 liters per minute unless otherwise ordered. The facility failed to follow its established protocols in both cases.
Medication Errors for Dialysis Patient
Resident 204, who received hemodialysis treatments three times weekly for end-stage renal disease, did not consistently receive prescribed Sevelamer medication as ordered. Sevelamer is a phosphate binder that controls high blood phosphorus levels in dialysis patients—a critical medication because elevated phosphorus can cause serious complications including cardiovascular disease, bone disease, and calcification of soft tissues.
The physician ordered two 800-milligram tablets of Sevelamer to be given by mouth with meals on hemodialysis days (Tuesdays, Thursdays, and Saturdays). However, medication administration records showed the medication was documented as "absent from home without meds" on February 27, March 1, March 4, and March 6, 2025, meaning Resident 204 did not receive these doses.
When residents leave the facility for dialysis appointments, staff must ensure prescribed medications accompany the resident or coordinate with the dialysis center to administer necessary medications. The facility's policy on end-stage renal disease care specifically addressed timing and administration of medications before and after dialysis and required agreements with dialysis facilities regarding how resident care and information exchange would be managed.
Licensed nursing staff acknowledged that Resident 204 did not receive the Sevelamer medication as ordered and confirmed the medication was not consistently administered before the resident left for dialysis. This failure meant the resident missed multiple doses of a medication essential for managing a life-threatening chronic condition.
Infection Control Breaches During Medication Administration
Inspectors observed multiple instances of inadequate hand hygiene and infection control practices during medication administration, creating risks for disease transmission among vulnerable residents. During observations on March 5, 2025, a Licensed Vocational Nurse failed to perform hand hygiene at critical points while administering medications to three residents.
When administering insulin to Resident 48, the nurse removed contaminated gloves after wiping blood from the resident's finger, retrieved additional supplies from the medication cart without performing hand hygiene, then donned new gloves and continued the procedure. The nurse touched the medication cart with contaminated hands, potentially transferring blood-borne pathogens to surfaces that would be touched repeatedly throughout the shift.
For Residents 58 and 59, the nurse failed to perform hand hygiene before and after medication administration and before and after touching residents. Hand hygiene represents the single most effective measure for preventing transmission of healthcare-associated infections. Medication administration involves multiple opportunities for pathogen transfer—from medication cart to nurse's hands, from hands to resident, from resident back to hands, and from hands to the next resident.
Healthcare-associated infections affect approximately one in 31 hospital patients on any given day, and nursing home residents face similar or greater risks due to advanced age, multiple chronic conditions, and frequent antibiotic exposure. Common organisms transmitted via inadequate hand hygiene include methicillin-resistant Staphylococcus aureus (MRSA), Clostridioides difficile, norovirus, and multidrug-resistant gram-negative bacteria.
The facility's hand hygiene policy specified that alcohol-based hand rub or soap and water should be used before and after direct contact with residents, before preparing or handling medications, after contact with intact skin, after removing gloves, and after contact with objects in the immediate vicinity of residents. Nursing staff acknowledged during interviews that they should perform hand hygiene before and after administering medications and before and after touching residents.
Failure to Use Isolation Precautions
A Certified Nurse Assistant entered the room of Resident 355, who was on contact isolation precautions due to bacteremia (bacteria in the bloodstream), without wearing required personal protective equipment. The resident's room had clear signage indicating "See nurse before entering the room" and a bin containing gloves, gowns, and other protective equipment outside the door.
The nursing assistant entered the room without gloves or gown, assisted the resident with a cellphone, then exited without performing hand hygiene. Contact precautions require healthcare workers to don gloves and gowns before entering the patient's room and to remove this equipment and perform hand hygiene before leaving the room. These precautions prevent transmission of infections spread by direct contact or contact with contaminated environmental surfaces.
When interviewed, the nursing assistant acknowledged the facility's policy required personal protective equipment when providing direct care to residents on contact isolation. The assistant stated the next time hand hygiene would be performed would be when entering another resident's room—meaning contaminated hands could touch doors, railings, medication carts, and other surfaces throughout the facility.
Facility nursing leadership confirmed that staff must perform hand hygiene and don gowns and gloves before entering isolation rooms and must remove equipment and perform hand hygiene before exiting. Proper isolation precautions prevent spread of infections, organisms, and bacteria to other vulnerable residents who may have compromised immune systems.
Additional Issues Identified
Inspectors documented several other violations during the survey. The facility failed to ensure the registered dietitian completed required quarterly nutritional assessments for Resident 18, whose last assessment occurred in November 2024 despite facility policy requiring quarterly reviews. Sharps containers on two medication carts were filled past the full-line indicator, increasing needlestick injury risks for staff. The facility failed to conduct initial rehabilitation screening for Resident 455, a hospice patient who expressed wanting to regain strength and function in his left arm and leg.
Food safety violations included expired parsley flakes and bread past the best-by date, food debris under kitchen equipment, improper storage of serving scoops, and wet serving trays stacked together rather than air-dried. Outside dumpsters were observed overflowing with lids not completely closed, creating conditions that attract pests and spread disease.
Valley Healthcare Center is an 86-bed facility located at 1680 North Waterman Avenue in San Bernardino. The inspection occurred March 3-7, 2025, as part of the standard federal survey process that evaluates nursing homes' compliance with Medicare and Medicaid participation requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley Healthcare Center from 2025-03-07 including all violations, facility responses, and corrective action plans.
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