Medical Center Convalescent Hospital
Medical Center Convalescent Hospital in San Bernardino, CA — inspection on February 26, 2026.
Found 12 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
(Resident 17) did not self-administer medication, when the facility assessment indicated Resident 17
a temporary, authorized absence from a medical facility for social, family, or therapeutic reasons, with the explicit requirement that they return for continued treatment from the facility).
This failure had the potential for Resident 17 to have adverse effects.Findings:A review of Resident's admission Record, (a document showing a summary of the resident's information) dated 2/25/26 indicated Resident 17 was admitted to the facility on [DATE].A review of Resident 17's History and Physical (H&P), dated 11/18/25, indicated Resident 17 had a surrogate decision maker and was noted to have confusion in the Neurological Exam portion.
The H&P also indicated Resident 17 had diagnoses including right sided weakness, seizures, and hypertension (high blood pressure).
Further review of the H&P indicated Resident 17 had fluctuating capacity to understand and make decisions.During an observation on 2/25/26 at 8:10 AM, Resident 17's bed was made and Resident 17 was not in the room.A review of Resident 17's Social Services Notes, dated 2/24/26 at 1:51 PM, indicated Resident 17 was out on pass for four days.A review of Resident 17's Order Summary Report, dated 2/25/26, showed a physician's order dated 2/23/26, May go OOP (out on pass) overnight from 2/24/26 to 2/28/26 one time only for 4 days.
Further review of The Order Summary Report, dated 2/25/26 also indicated the following physician's orders:- Order dated 1/21/26, for Keppra (a medication used to treat seizures) oral tablet 500 mg ([milligrams] - unit of measurement), give 500 mg by mouth every 12 hours related to conversion disorder with seizures or convulsions.- Order dated 1/21/26, for Nifedipine (medication used to treat high blood pressure or chest pain) oral tablet extended release 24 hr (hours) 30 mg.A review of Resident 17's Self Administration of Medication Assessment, dated 10/31/25, indicated Resident 17 was not a candidate for safe self-administration of medications.
Further review of Resident 17's Self Administration of Medication Assessment, indicated the facility assessed the resident as No for mental and physical capacity to self administer medications.During a concurrent interview and record review with Director of Nursing (DON), Resident 17's medical record was reviewed.
The DON stated Resident 17 went out on pass on 2/24/26.
The DON stated Resident 17 was sent with medications to self-administer, as evidenced by the medication being removed from the bubble pack (a card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles, usually organized by day and time).
The DON reviewed Resident 17's Self Administration of Medication Assessment, dated 10/31/25, and confirmed Resident 17 was unable to safely self-administer medication.A review of the facility's policy titled, Policy and Procedure on Self-Administration of Medications, indicated .as part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications.If the staff determines that a resident cannot safely self-administer medications, the nursing staff will administer the residents medications.Cross Reference to F-F689 #1.
056436 02/26/2026
Medical Center Convalescent Hospital 467 E Gilbert St San Bernardino, CA 92404
use for one of one sampled resident (Resident 2).This failure had the potential for Resident 2's care
Resident 2 was observed sitting up in bed. Resident 2's call light was observed on the floor to the left side of Resident 2's bed.
The Licensed Vocational Nurse (LVN 1) was observed exiting Resident 2's room.During a concurrent observation and interview on 2/23/26 at 9:50 AM with LVN 1 inside Resident 2's room, Resident 2's call light was observed on the floor to the left side of Resident 2's bed. LVN 1 verified the call light was not within Resident 2's reach and acknowledged it should have been accessible. LVN 1 stated Resident 2 was at risk for falls and having the call light within reach was important for Resident 2 to request assistance.A review of Resident 2's admission Record, (a document showing a summary of the resident's information) dated 2/25/26, indicated Resident 2 was readmitted to the facility on [DATE].A review of Resident 2's Minimum Data Set ([MDS], a standardized assessment tool) dated 12/23/25, indicated Resident 2 was dependent (helper did all the effort, resident did none of the effort to complete the activity) on staff with toileting, showering and lower body dressing.A review of Resident 2's Care Plan Report, indicated a Focus area titled Resident at risk for falling . dated 6/18/25, indicated an intervention to Keep call light in reach.During an interview on 2/26/26 at 7:40 AM, with the Director of Nursing (DON), the DON stated the importance of call lights was to ensure residents were able to alert and communicate with staff.A review of the facility's policy and procedure (P&P) titled Call Light/Bell, revised 12/14, indicated 6.
Place the call device within resident's reach before leaving room.
056436 02/26/2026
Medical Center Convalescent Hospital 467 E Gilbert St San Bernardino, CA 92404
During a concurrent interview and record review on 2/26/26 at 1:24 PM with the Director of Nursing (DON), the DON confirmed residents have the right to ask for and see the results of the survey binder.
The DON acknowledged the survey binder was placed in an area that was not readily accessible to residents. A review of the facility's policy and procedures (P&P), titled Resident Rights, revised 11/14, indicated, .
You may examine survey results and the plan of correction.
These, or a notice of location, will be posted in a readily accessible place.
056436 02/26/2026
Medical Center Convalescent Hospital 467 E Gilbert St San Bernardino, CA 92404
During a concurrent interview and record review on 2/24/26 at 11:23 AM, with the SSD, the SSD was asked about the procedure for Advance Directives.
The SSD stated that she was responsible for talking to the residents if they wanted help to formulate an Advance Directive, and it would be documented in the resident's chart.
The SSD reviewed the medical records for the residents above and was unable to show written documentation help had been offered to formulate an Advance Directive.
During a concurrent observation, interview and record review with the Director of Nursing (DON) on 2/25/26 at 2:30 PM at the nurses' station by the front lobby area, the DON stated facility P&Ps were reviewed annually and revised and updated as needed.
The DON further stated facility P&Ps were also reviewed during Quality Assurance and Performance Improvement (QAPI - a data driven proactive approach to improvement used to ensure services are meeting quality standards) meetings.
A review of the facility's policies and procedures (P&P) titled, Advanced Directives, revised 7/12, indicated, .1.
Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical surgical treatment, and the right to formulate advance directives.
056436 02/26/2026
Medical Center Convalescent Hospital 467 E Gilbert St San Bernardino, CA 92404
During a concurrent interview and record review with Registered Nurse 2 (RN 2) on 2/24/26 at 10:59 AM, RN 2 reviewed Resident 6's Preadmission Screening and Resident Review PASSR - Level 1 Screening, dated 10/17/25, and Resident 6's Notice of Attempted Evaluation, dated 10/21/25.
RN 1 stated they were responsible for completing and following up on the PASRR for the residents in the facility. RN 1 stated the process of the PASSR determined if residents required special services or if the residents were appropriate to stay in the facility. RN 1 was asked to provide documented evidence that the facility followed up on the attempted PASSR Level II Screening. RN 1 was unable to provide such evidence and stated it was missed, and it should have been completed.During a concurrent interview and record review with the Director of Nursing (DON) on 2/26/26 at 7:51 AM, the DON verified the PASSR was not completed.
The DON stated completing the PASSR was important to ensure the services and placement at the facility was appropriate for Resident 6.A review of the facility's policy and procedure (P&P) titled PAS/PASSAR, revised 03/05, indicated, .PASARR should be completed for all residents .
For the residents found to be mentally ill . this screening is used to determine whether the nursing facility care is appropriate and whether the resident needs specialized services.
056436 02/26/2026
Medical Center Convalescent Hospital 467 E Gilbert St San Bernardino, CA 92404
During a concurrent interview and record review on 2/24/26 at 5:08 PM with the Licensed Vocational Nurse 3 (LVN 3), Resident 3's MAR for January and February 2026 were reviewed. LVN 3 verified the missing signatures on the MAR and stated licensed staff were responsible for monitoring and documenting the input and output of residents who had an order for an indwelling urinary catheter.
LVN 3 stated that documenting the intake and output on the MAR would ensure the monitoring was completed.
During a concurrent interview and record review on 2/26/26 at 7:43 AM with the Director of Nursing (DON), the DON acknowledged the missing MAR documentation for January and February 2026 and stated the licensed staff must ensure intake and output monitoring was documented in the MAR.
The DON further stated the importance of monitoring the intake and output included assessing Resident 3's hydration status and the quality, color, odor, and consistency of Resident 3's urine.A review of the facility's policy and procedure (P&P) titled, Intake and Output, revised 07/2012, indicated It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance for resident admitted with indwelling foley catheter . I&O assessments will be documented in the resident's medical record.
Include average intake, average output, quality, color, odor, consistency of urine, resident's hydration status.
056436 02/26/2026
Medical Center Convalescent Hospital 467 E Gilbert St San Bernardino, CA 92404
During an observation on 2/23/26 at 3:56 PM, Resident 84 was smoking on the patio.
During a concurrent interview and record review on 2/24/26 at 3:28 PM, the Admissions Director was asked about the process for residents who wish to smoke at the facility.
The Admissions Director stated the facility had to complete a smoking assessment to determine if the resident smoked and was safe to smoke at the facility.
The Admissions Director reviewed Resident 84's medical record and stated Resident 84 did not have a smoking assessment completed until 2/24/26 and should not have been smoking prior to that time.
A review of the facility's policy and procedures (P&P) titled Smoking Policy, dated 7/12, showed that .Facility attempt to keep and maintain our residents, staff, and visitors free from any hazardous accidents.
This includes but not limited to fire which could be due to unsafe smoking practice.
056436 02/26/2026
Medical Center Convalescent Hospital 467 E Gilbert St San Bernardino, CA 92404
During a concurrent interview and record review on 2/23/26 at 10:00 AM with the Licensed Vocational Nurse 2 (LVN 2), Resident 3's TAR for January and February 2026 were reviewed. LVN 2 verified the missing signatures on the TAR and stated licensed staff were responsible for signing the TAR after the urinary catheter care was completed. LVN 2 stated that documenting information on the TAR would ensure the urinary catheter care was completed and who the care was completed by.
During a concurrent interview and record review on 2/26/26 at 11:19 AM with the Director of Nursing (DON), the DON acknowledged the missing TAR documentation for January and February 2026 and stated the licensed staff must ensure indwelling catheter care was documented to verify that the care was provided.
The DON further stated failure to provide catheter care placed residents with an indwelling catheter at risk for infection.A review of the facility's policy and procedure (P&P) titled, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, revised June 2014, indicated The following catheter-associated urinary tract infections (CAUTI) prevention strategies have been adopted and are to be followed by clinical staff: . 7.
Perform daily meatal (external opening where urine exits the body) hygiene with soap and water for residents with indwelling catheter.
056436 02/26/2026
Medical Center Convalescent Hospital 467 E Gilbert St San Bernardino, CA 92404
below beyond use dates as long as the manufacturer expiry date is not exceeded. [the name of the
1/21/26, the P&P indicated, Policy: Medications and biologicals are stored safely, securely, and
concurrent observation and interview on 2/23/26, at 7:56 AM, an inspection of Medication Room A was conducted with the MDS.
Two opened and undated multiple-dose vials of tuberculin purified protein derivative (Aplisol) were observed stored in the medication refrigerator.
The MDS acknowledged the opened and undated Aplisol vials were stored in the Medication Room A refrigerator.
During an interview on 2/26/26, at 9:30AM, with the Infection Preventionist (IP), the IP stated Aplisol vial is to be dated because it is only good for a certain time.
During an interview on 2/26/26, at 9:37 AM, with RN 2, RN 2 stated the Aplisol vial is labeled with the date when it is opened to determine when to discard it.
During an interview on 2/26/26, at 9:54 AM, with the DON, the DON stated the expectation is once the Aplisol vial is opened, it should be dated and kept no longer than 30 days.During a review of the Aplisol package insert (PI - document on how to safely use medications) dated May 2024, provided by the facility, the PI indicated, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.During a review of the facility's P&P titled, Medication Labeling and Storage, revised 2/23, the P&P indicated, Multi-dose vials that been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
056436 02/26/2026
Medical Center Convalescent Hospital 467 E Gilbert St San Bernardino, CA 92404
During a concurrent observation and interview on 2/25/26, at 7:56 AM, an inspection of the Central Supply storage area was conducted with the Environmental Services Director (ESD) and Central Supply Staff (CSS).
Multiple bottles of Dakins Quarter (to treat and prevent skin and tissue infections) solution with a National Drug Code (NDC) 0436-0672-16 and multiple cartons of triple antibiotic ointment (to treat and prevent minor skin infections) with a NDC 67777-217-14 were observed stored in the Central Supply storage area.
The product labeling on the Dakins Quarter solution indicated to store at room temperature between a range of 20-25C (68-77F).
The product labeling on the triple antibiotic ointment to store at room temperature between a range of 15-30C (59-86F).
The ESD acknowledged the temperature range indicated on the product labeling on the bottles of Dakins Quarter solution and the cartons of triple antibiotic ointment.
The ESD stated there were no temperature logs for the medications stored in the Central Supply storage area.
During an interview on 2/26/26, at 9:54 AM, with the DON, the DON stated the facility threw away medications observed in the Central Supply storage area on February 25, 2026, because there were no temperature logs.During a review of the Dakins Quarter solution PI dated June 2025, provided by the facility, the PI indicated, Store at room temperature.During a review of the triple antibiotic ointment PI dated June 2025, provided by the facility, the PI indicated, Store at room temperature between 15C - 30C (59 - 86F).During a review of the facility's P&P titled, Medication Labeling and Storage, revised February 2023, the P&P indicated, The facility stores all medications and biologicals in locked compartments under proper temperature.During a review of the facility's P&P titled, MEDICATION STORAGE IN THE FACILITY, reviewed 1/21/26, the P&P indicated, Procedure.Medications requiring storage at room temperature are kept at temperatures ranging from 15C (59C) to 30C (86F).
056436 02/26/2026
Medical Center Convalescent Hospital 467 E Gilbert St San Bernardino, CA 92404
During a concurrent follow up observation and interview of the kitchen on 2/25/26, at 11:10 AM, with the DS, wet dishes were found stacked on top of each other and not air dried.
The DS stated that all dishes should be air dried before storing.A review of the facility's undated P&P titled, 3 Compartment Procedure for Manual Dishwashing was reviewed.
The P&P indicated, .
Step 6: All items are air-dried, which means no water droplets are present.A review of the 2022 FDA (Food and Drug Administration) Food Code, 4-901.11 indicated, Equipment and Utensils, Air-Drying Required .After cleaning and SANITIZING, EQUIPMENT and UTENSILS: ((A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
056436 02/26/2026
Medical Center Convalescent Hospital 467 E Gilbert St San Bernardino, CA 92404
in accordance with accepted professional standards.
failed to maintain an accurate Medication Administration Record ([MAR] - a daily documentation
of one sampled resident (Resident 17) when the facility indicated Resident 17 was hospitalized , while the resident was out on pass ([OOP] - a temporary, authorized absence from a medical facility for social, family, or therapeutic reasons, with the explicit requirement that they return for continued treatment from the facility).This failure had the potential for omission of necessary medications.Findings:A review of Resident 17's admission Record, (a document showing a summary of the resident's information) dated 2/24/26, indicated Resident 17 was admitted to the facility on [DATE].A review of Resident 17's Release for Temporary Absence form undated, indicated Resident 17 departed the facility on 2/24/26 at10:08 AM.During an observation on 2/25/26 at 8:10 AM Resident 17 was not in the room and the bed was made.During a concurrent interview and record review on 2/25/26 at 10:58 AM with the Director of Nursing (DON), Resident 17's Medication Administration Record, dated 2/1/26 - 2/28/26, was reviewed.Resident 17's MAR indicated:- On 2/25/26, the dose at 7:00 am for losartan potassium (a medication for high blood pressure) 100 milligrams (mg - unit of measurement) was marked with a number 6 with an initial of KB08,- On 2/25/26, the dose at 7:00 am for carvedilol (a medication for high blood pressure) 3.125 mg was marked with a number 6 with an initial of KB08.Further review of Resident 17's MAR, the record chart codes indicated the number 6 meant the resident was hospitalized .The DON verified the above findings.
The DON acknowledged Resident 17 was provided with the resident's medications while out on pass.
The DON further stated the resident would be out on pass until 2/28/26.
The DON stated the medications above should have been marked with number 11 since the resident was out on pass.
The number 6 documented in Resident 17's MAR was not an accurate code to reflect the status of the resident.
The DON further stated the initial KB08 was the initial of the licensed nurse who documented the in the resident's MAR as described above.