Cycle 1
Health 2025-08-27 · Fire 2025-08-27
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
San Bernardino, CA
Community Hospital Of San Bernardino Dp SNF
3-star overall rating with 3-star inspections with $9,110 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1805 Medical Ctr Dr., San Bernardino, CA
(909) 887-6333
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
85
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Commonspirit Health
Operator or chain grouping
Approved since
1992-09-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.13
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
3.97
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.85
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
7.95
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
5.10
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
7.06
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
3.29
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,859
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.32
Composite VBP score used to determine payment impact.
Payment multiplier
1.0009
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
9.46
Performance 25.00% · Measure score 9.46 · Achievement 9.46 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.81 hours · Performance 1.67 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.28% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 156 |
| Staff flu vaccination coverage | 57.99% |
42%
16 pts better
|
Numerator 98 · Denominator 169 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 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 who lose too much weight | 0.6% |
4.1%
3.5 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.6% |
13.7%
18.9 pts worse
|
19.6%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 32.9% · Q3 33.0% · Q4 31.0% · 4Q avg 32.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
14.2%
5.7 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q3 8.0% · Q4 8.7% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 9.9% |
0.4%
9.5 pts worse
|
0.1%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 10.6% · Q3 10.2% · Q4 8.2% · 4Q avg 9.9% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
1.0%
3.4 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.7% · Q3 4.4% · Q4 4.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.2%
About the same
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 0.0% |
10.9%
10.9 pts better
|
19.8%
19.8 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 with pressure ulcers | 13.1% |
4.7%
8.4 pts worse
|
5.1%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 15.0% · Q3 16.3% · Q4 11.1% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-16 · Fire 2024-08-16
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-06-08 · Fire 2023-06-08
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-10
F · Potential for more than minimal harm
2025-08-27
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-08-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-27
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-17
F · Potential for more than minimal harm
2024-08-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-16
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2024-09-10
D · Potential for more than minimal harm
2023-06-08
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-05
Inspection history
Recent health citations
G · Actual harm
2025-11-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-14
G · Actual harm
2025-10-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-31
F · Potential for more than minimal harm
2025-08-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-27
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-27
F688 · Quality of Life and Care Deficiencies
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 2025-09-20
D · Potential for more than minimal harm
2025-08-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-27
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2025-09-20
F · Potential for more than minimal harm
2024-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-15
F · Potential for more than minimal harm
2024-08-16
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-09-15
D · Potential for more than minimal harm
2024-08-16
F693 · Quality of Life and Care Deficiencies
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 2024-09-15
D · Potential for more than minimal harm
2024-08-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-15
F · Potential for more than minimal harm
2023-06-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-14
E · Potential for more than minimal harm
2023-06-08
F693 · Quality of Life and Care Deficiencies
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 2023-07-14
D · Potential for more than minimal harm
2023-06-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-08
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-08
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-08
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-07-14
Penalties and ownership
What sits behind the stars
$9,110
2025-11-20
Fine
Fine · fine $9,110
Fine
Ownership
Collison, June
Corporate Officer · Individual
Collison, June
W-2 Managing Employee · Individual
Commonspirit Health
Operational/Managerial Control · Organization
Community Hospital Of San Bernardino
5% Or Greater Direct Ownership Interest · Organization
Daly, Gail
Corporate Director · Individual
Davis, Claudia
Corporate Director · Individual
Dignity Community Care
5% Or Greater Direct Ownership Interest · Organization
Dignity Health
5% Or Greater Direct Ownership Interest · Organization
Evans, David
Corporate Officer · Individual
Evans, David
W-2 Managing Employee · Individual
Gonzalez, Richard
Corporate Director · Individual
Henley, Nicole
Corporate Director · Individual
Lee, Vicki
Corporate Director · Individual
Mawad, Joseph
Corporate Director · Individual
Myrell, Antonio
Corporate Director · Individual
Negusse, Johnny
Corporate Director · Individual
O'quinn, Marvin
Operational/Managerial Control · Individual
Petersdorf, John
Corporate Officer · Individual
Ramirez, Gabriel
Corporate Director · Individual
Scharmann, Steven
Corporate Officer · Individual
Wenger, Rachelle
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Community Convalescent Center Of San Bernardino
San Bernardino, CA
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Arrowhead Springs Healthcare
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
#3
Medical Center Convalescent Hospital
San Bernardino, CA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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