7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
San Bernardino, CA
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1335 N. Waterman Ave., San Bernardino, CA
(909) 885-0268
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
119
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1971-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.31
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.61
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.86
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.78
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.92
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.08
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
4.66
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
2,619
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.72
Composite VBP score used to determine payment impact.
Payment multiplier
1.0025
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.25
Performance 19.46% · Measure score 4.25 · Achievement 4.25 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.29
Baseline 8.02% · Performance 6.57% · Measure score 4.29 · Achievement 4.24 · Improvement 4.29
Total nurse turnover
7.35
Performance 33.62% · Measure score 7.35 · Achievement 7.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.59
Baseline 2.63 hours · Performance 3.92 hours · Measure score 3.59 · Achievement 2.96 · Improvement 3.59
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.19% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 10.71% · Lower 95% interval 6.6% |
| Discharge to community | 43.33% |
50.57%
7.2 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 28.57% · Lower 95% interval 29.87% |
| Medicare spending per beneficiary | 1.37 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98.94% |
95.27%
3.7 pts better
|
Numerator 93 · Denominator 94 |
| Falls with major injury | 1.06% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 94 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 25 · Denominator 40 |
| Discharge mobility score | 42.5% |
50.94%
8.4 pts worse
|
Numerator 17 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 1.06% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 94 · Adjusted rate 0.74% |
| Healthcare-associated infections requiring hospitalization | 6.57% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 3.18% |
| Staff COVID-19 vaccination coverage | 5.21% |
8.2%
3 pts worse
|
Numerator 10 · Denominator 192 |
| Staff flu vaccination coverage | 33.94% |
42%
8.1 pts worse
|
Numerator 74 · Denominator 218 |
| Discharge function score | 52.5% |
56.45%
4 pts worse
|
Numerator 21 · Denominator 40 |
| Transfer of health information to provider | 90% |
95.95%
6 pts worse
|
Numerator 27 · Denominator 30 |
| Transfer of health information to patient | 90.24% |
96.28%
6 pts worse
|
Numerator 37 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 17.39% |
25.2%
7.8 pts worse
|
Numerator 8 · Denominator 46 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 3.3 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
98.5%
1.2 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
98.2%
0.6 pts worse
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
1.6%
0.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.4% · Q3 1.5% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 24.3% |
6.8%
17.5 pts worse
|
11.4%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 31.2% · Q3 19.0% · Q4 9.7% · 4Q avg 24.3% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
4.1%
1.5 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.5% · Q3 1.6% · Q4 0.0% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.4% |
13.7%
8.3 pts better
|
19.6%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.2% · Q3 3.1% · Q4 7.4% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
14.2%
8 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 2.9% · Q3 10.0% · Q4 2.4% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.3% |
11.0%
1.7 pts better
|
16.3%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
10.7%
4.1 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.2% · Q3 7.1% · Q4 6.7% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.0%
0.3 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.2%
0.8 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.7% |
10.9%
3.2 pts better
|
19.8%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.6% · Q3 5.3% · Q4 15.6% · 4Q avg 7.7% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
4.7%
3.8 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 9.2% · Q3 4.0% · Q4 8.2% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
94.0%
3.4 pts worse
|
81.7%
8.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.3% · Q2 89.9% · Q3 93.5% · Q4 93.8% · 4Q avg 90.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
11.2%
2.6 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 9.8% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.5% · Q4 0.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
93.2%
1.9 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
23.2%
3.4 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 26.8% · Expected 32.3% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nutrition and Dietary (4 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-05-07
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-07-06
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-07-06
Fire Safety
Use approved construction type or materials.
Corrected 2022-07-06
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2022-07-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-06
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-07-06
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-07-06
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-06
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-07-06
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-06
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-01-27
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-01-27
Fire Safety
List the names and contact information of those in the facility.
Corrected 2020-01-27
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-01-27
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2020-01-27
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-01-27
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-01-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-27
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-27
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-01-27
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-01-27
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2020-01-27
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-01-27
Fire Safety
Provide emergency officials' contact information.
Corrected 2020-01-27
Inspection history
Health
Dispose of garbage and refuse properly.
Corrected 2025-05-16
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-05-16
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-16
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-16
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-05-16
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-16
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-15
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-06
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-14
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-14
Health
Keep all essential equipment working safely.
Corrected 2022-06-22
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-06-22
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-06-22
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-22
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-06-22
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-06-22
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-06-22
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-06-22
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-22
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2019-11-12
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2019-11-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-11-12
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-11-12
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-11-12
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-11-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-11-12
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2019-11-12
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2019-11-12
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-12
Health
Keep all essential equipment working safely.
Corrected 2019-11-12
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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