Haven Post Acute: Unreported Fall Goes Undocumented - CA
The resident was a woman with Alzheimer's disease, already admitted to Haven Post Acute for follow-up care on a fracture that was still healing. When inspectors reviewed her clinical records during a complaint inspection on March 17, 2026, the fall she reported to staff on March 3 did not exist anywhere in her chart.
Two licensed vocational nurses went through the records together with inspectors that afternoon. They found nothing.
The registered nurse who responded to the scream, identified in the inspection report as RN 1, described what happened during a phone interview the following day. She said she heard the scream, went to the room, and found the resident in bed saying she had fallen. The resident appeared disoriented and couldn't answer follow-up questions about what had happened. RN 1 said she examined the woman's body and found no signs of injury.
Then she left, and wrote nothing down.
The Director of Nursing said she went looking for RN 1's documentation after inspectors raised the issue and couldn't find it either. She was direct about what should have happened: the incident needed to be documented regardless of the resident's Alzheimer's diagnosis. A reported change in condition required a record.
When inspectors spoke with RN 1 again the next morning, she acknowledged it. She said she failed to document the reported fall and her assessment of the resident. She called it her oversight.
The resident at the center of this had a score of 12 on the Brief Interview for Mental Status, a cognitive screening tool administered on the same day as the reported fall, March 3, 2026. A score in the range of 8 to 12 indicates moderate problems with thinking and memory. She had Alzheimer's disease. She was recovering from a fracture. And when she told a nurse she had fallen, that report vanished.
What makes the gap significant is not just the missing paperwork. It's what the paperwork is for. A medical record that doesn't reflect a resident's reported fall means the care team working the next shift, the next day, the following week, has no way of knowing it happened. If the resident's condition changed, if pain emerged, if something had been injured that the bedside assessment missed, no one reading her chart would have any reason to connect it to a fall on March 3.
The facility's own documentation policy, in place since July 2017, lists the categories of information that must go into a resident's medical record. Changes in condition are on the list. Events, incidents, and accidents are on the list. Treatments and services performed are on the list. The policy describes the medical record as a communication tool for the interdisciplinary team.
On March 3, 2026, that communication broke down entirely for this resident.
The inspection, a complaint survey completed March 30, 2026, cited the facility for failing to maintain complete and accurate medical records. The finding covered one of three residents whose records were reviewed. Inspectors rated the level of harm as minimal harm or potential for actual harm.
Whether any harm resulted from the missing documentation, no one can say with certainty now. The assessment RN 1 conducted that evening found no injuries. But the resident who reported the fall, a woman with moderate cognitive impairment and a healing fracture, had no reliable way to tell the next nurse who walked into her room what had happened to her the night before. Her chart couldn't tell them either.
RN 1 knew the policy. She said so herself.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Haven Post Acute from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
HAVEN POST ACUTE in SAN BERNARDINO, CA was cited for violations during a health inspection on March 30, 2026.
The resident was a woman with Alzheimer's disease, already admitted to Haven Post Acute for follow-up care on a fracture that was still healing.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.