Other·February 19, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey to investigate two facility reported incidents. Facility Reported Incident Numbers: CA00661363, and CA00661453 Representing the California Department of Public Health 41277 The inspection was limited to the specific facility reported incident investigation and does not represent the findings of a full inspection of the facility. One deficiency was issued for the two facility reported incidents numbers: CA00661363, and CA00661453

F602 SS=H Free from Misappropriation/Exploitation CFR(s): 483.12

F602 02/15/2020 §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This REQUIREMENT is not met as evidenced by: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 Facility ID: CA240000058 If continuation sheet 1 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056053 (X3) DATE SURVEY COMPLETED 01/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAVEN POST ACUTE 1311 E Date St San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to protect eleven out of eleven sampled residents in a universe of 93 residents (Residents A, B, C, D, E, F, G, H, I, J, K) from misappropriation of property, when money was taken without their consent as follows: 1. Resident A reported $80.00 dollars was missing from his bedside table. 2. Resident B had $720.00 dollars taken from his wallet. 3. Resident C had $20.00 dollars taken from his wallet. 4. Resident D had $25.00 dollars taken from her bedside table. 5. Resident E had $400.00 dollars taken from his wallet. 6. Resident F had $60.00 dollars and his debit card taken from his bedside table. 7. Resident G had $25.00 dollars taken and then $403.00 charged on her debit card fraudulently by a Certified Nurse Assistant (CNA 1). 8. Resident H had $160.00 dollars taken from his wallet from his bedside drawer. 9. Resident I had $26.00 taken from her wallet at her bedside table. 10. Resident J had $80.00 taken from her wallet at her bedside table. 11. Resident K had $30.00 taken from his wallet and $35.00 dollars from his glass case. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 Facility ID: CA240000058 If continuation sheet 2 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056053 (X3) DATE SURVEY COMPLETED 01/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAVEN POST ACUTE 1311 E Date St San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE In addition, the facility failed to thoroughly investigate Residents' (A, B, C, D, E, F, G, H, I, J and K's) complaints about theft and loss of their money until it was addressed by the California Department of Public Health. These failures had the potential for continued theft to go undetected and to not be investigated by the facility placing all residents at risk of emotional distress and misappropriation of their property. Findings: 1. During an observation with Resident A, on October 25, 2019, at 10:30 AM, observed resident sitting in her wheelchair watching television. Resident A was asked if she ever had any property misplaced. Resident A stated she had $80.00 dollars she hid her money under her bible that was on the over-bed table by her bed. Resident A stated she went out to the patio to smoke and came back into her room and her money was gone. Resident A stated she informed Social Services (SS 1), and filled out a loss and theft form. Resident A stated she was reimbursed $20.00 by SS 1, and when she received the money she placed the $20.00 in her pillow case to hide her money, and it was gone the following morning. "I can't trust anyone here." Resident A further stated she gave the Certified Nurse Assistant (CNA 1) her pin code to her debit card so the CNA 1 could buy Resident A one pack of cigarettes. Resident A stated that CNA 1 took her debit card and purchased the cigarettes, but also purchased an item without Resident A's permission. During a review of Resident A's "Theft and Loss Report" dated August 5, 2019, the report indicated $80.00 dollars was missing from Resident A's beside table. Resident A was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 Facility ID: CA240000058 If continuation sheet 3 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056053 (X3) DATE SURVEY COMPLETED 01/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAVEN POST ACUTE 1311 E Date St San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reimbursed $20.00 dollars. During a review of Resident A's Change of Condition documentation dated October 25, 2019, indicated "Allegation of staff stealing money from debit card." The nurse wrote, "Resident encouraged not to give any money to staff and understood." A review of Resident A's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated October 16, 2019, indicated the resident was cognitively intact. 2. During a review of Resident B's "Theft and Loss Report" dated August 20, 2019, the report indicated $720.00 dollars was missing from Resident B's wallet. Resident B was not reimbursed. A police report was made on-line. A review of Resident B's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated August 20, 2019, indicated the resident was cognitively intact. During an interview with the Director of Nurses (DON) on October 23, 2019, at 3:00 PM, the DON stated if a resident had anything lost or stolen they will fill out a theft or loss form. "If the amount is greater than $100.00 we will file a police report." 3. During an interview with Resident C, on October 25, 2019, at 11:00 AM, Resident C stated he had $80.00 dollars in his wallet which he keeps in the front pocket of his backpack. Resident C stated he left the facility for an hour. Resident C further stated he looked through his backpack and his money was gone and his wallet was not in the same place where he had placed it which was in the front pocket of his backpack. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 Facility ID: CA240000058 If continuation sheet 4 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056053 (X3) DATE SURVEY COMPLETED 01/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAVEN POST ACUTE 1311 E Date St San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of the Resident C's "Theft and Loss Report" dated August 18, 2019, the report indicated $20.00 dollars was missing from Resident C's wallet. Resident C was reimbursed $20.00 dollars. A review of Resident C's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated October 14, 2019, indicated the Resident C was cognitively intact. 4. During an interview with Resident D, on October 25, 2019, at 10:00 AM, Resident D stated she has had her money stolen, "several times." Resident D stated that her clothing had gone missing and she filled out a theft and loss form. SS I reimbursed Resident A $75.00 for her lost clothing. Resident D further stated her CNA (CNA 2) was aware Resident D had received money. Resident D stated when she looked into her wallet, "not even an hour later," she only had $25.00 dollars. Resident D also stated she did not report this and now she hides her money in different places. During a review of Resident D's "Theft and Loss Report" dated July 22, 2019, the report indicated $25.00 dollars was missing from Resident D's bedside table. Resident D stated she was reimbursed $20.00 dollars. A review of Resident D's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated October 10, 2019, indicated the resident was cognitively intact. 5. During an interview with Resident E, on October 23, 2019, at 1:15 PM, Resident E stated on October 21, 2019, SS 1 brought him his wallet. Resident E stated that SS 1 told him his black wallet was found in the laundry room. Resident E stated he did not understand how FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 Facility ID: CA240000058 If continuation sheet 5 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056053 (X3) DATE SURVEY COMPLETED 01/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAVEN POST ACUTE 1311 E Date St San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE his wallet was in the laundry room when the wallet was inside his dresser in a pouch. Resident E further stated that SS 1 helped him fill out a police report on-line and Resident E stated, "I feel so violated." During a review of the Resident E's "Theft and Loss Report" dated October 21, 2019, the report indicated $400.00 dollars was missing from Resident E's pouch which was in his drawer next to his bed. Resident E was not reimbursed $400.00 dollars. A police report was made on-line. A review of Resident E's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated August 28, 2019, indicated Resident E was cognitively intact. During a phone interview with SS 1, on October 23, 2019, at 1:59 PM, SS 1 stated she was aware of Resident E's money and said that a police report was already filled out and it was still under investigation. 6. During an interview with Resident F, on October 25, 2019, at 11:55 AM, Resident F stated his money was in his wallet with his debit card. He stated he had $60.00 dollars, now both were missing. Resident F stated he called the bank right away and canceled his card. Resident F further stated, "I can't trust anyone here. This place should be closed down." During a review of the Resident F's "Theft and Loss Report" dated September 18, 2019, the report indicated $60.00 dollars, and debit card was missing from Resident F's bedside table. Resident F was reimbursed $20.00. A review of Resident F's Minimum Data Set [MDS- a comprehensive assessment and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 Facility ID: CA240000058 If continuation sheet 6 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056053 (X3) DATE SURVEY COMPLETED 01/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAVEN POST ACUTE 1311 E Date St San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE screening tool] dated August 2, 2019, indicated Resident F was cognitively intact. 7. During an interview with Resident G, on October 25, 2019, at 9:35 AM, Resident G stated she keeps her purse on her wheelchair. She said when she reached into her purse to pay for her candy bar, her $25.00 dollars was missing. Resident G filled out a loss and theft form and gave it to SS 1. Resident further stated she left her debit card in her personal belongings by her table when she went to play bingo for an hour. Resident G returned from playing bingo and her debit card was missing. Resident G informed SS 1 immediately and the SS 1, "went on-line to check if money was taken from my bank account." Resident G had $403.00 taken from her account. Resident G stated she filed a grievance and has not heard back from anyone. During a review of the Resident G's "Theft and Loss Report" dated August 28, 2019, the report indicated $25.00 dollars and debit card was missing from Resident G's wheelchair pouch. Resident G was reimbursed $20.00. A second Theft and Loss report dated August 29, 2019, indicated Resident G's debit card was missing. On the report was listed a bank account balance of $464 through August 2, 2019. On August 29, 2019 is listed a balance of (-) $403. Her card company was notified and attached was a letter from the "Fraud Services Department" dated September 11, 2019 indicating they would be investigating. A review of Resident G's Minimum Data Set [MD'S- a comprehensive assessment and screening tool] dated September 13, 2019, indicated Resident G was cognitively intact. 8. During a review of the Resident H's "Theft and Loss Report" dated September 15, 2019, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 Facility ID: CA240000058 If continuation sheet 7 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056053 (X3) DATE SURVEY COMPLETED 01/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAVEN POST ACUTE 1311 E Date St San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the report indicated $160.00 dollars was missing from Resident H's wallet in his drawer. Resident H was reimbursed $20.00. A review of Resident H's Minimum Data Set [MD'S- a comprehensive assessment and screening tool] dated September 4, 2019, indicated Resident H was cognitively intact. 9. During a review of the Resident I's "Theft and Loss Report" dated September 18, 2019, the report indicated $26.00 dollars was missing from Resident I's wallet at the bedside table. Resident I was reimbursed $20.00. A review of Resident I's Minimum Data Set [MD'S- a comprehensive assessment and screening tool] dated July 25, 2019, indicated Resident I was cognitively intact. 10. During a review of the Resident J's "Theft and Loss Report" dated September 15, 2019, the report indicated $80.00 dollars was missing from Resident J's wallet from her bedside table. Resident J was not reimbursed. A review of Resident J's Minimum Data Set [MD'S- a comprehensive assessment and screening tool] dated August 26, 2019, indicated the Resident J was cognitively intact. 11. During an interview with Resident K, on October 23, 2019, at 2:10 PM, Resident K stated it was in the morning, (does not recall which day) the S'S 1 came into Resident K's room and handed him his black wallet. S'S I told Resident K his wallet was found in the laundry room. "I always hide my money in my pillow case. I can't trust anyone here." Resident K verbalized being upset because the facility would not reimburse him. He stated he was told the money was not on his inventory list. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 Facility ID: CA240000058 If continuation sheet 8 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056053 (X3) DATE SURVEY COMPLETED 01/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAVEN POST ACUTE 1311 E Date St San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of the Resident K's "Theft and Loss Report" dated October 14, 2019, the report indicated $30.00 dollars was missing from Resident K's pillow case. Resident K was not reimbursed. A review of Resident K's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated October 8, 2019, indicated Resident K was cognitively intact. During an interview with the DON, on October 23, 2019, at 4:15 PM, the DON confirmed that they [the facility] have a problem with money missing and stated, "They are looking into it." During an interview with the Laundry Tech (LT 1), on October 25, 2019, at 9:20 AM, LT 1 stated she has found money, dentures, glasses, wallets, and turns them into her supervisor or SS 1. During an interview with the DON, on October 25, 2019, at 11:50 AM, the DON stated she was not aware of any nurses using Residents' debit cards or taking money. The DON confirmed that nurses are not allowed to accept money or use a Resident's debit card. During an interview with the Administrator, on October 25, 2019, at 12:31 PM, the Administrator confirmed that if money was missing, "We usually reimburse the Resident $20.00." When asked if they had checked the cameras the Administrator stated, "The cameras are not working at this time and are getting fixed." The Administrator identified and confirmed that the theft and loss of residents' money was an issue, but was not currently part of their QAPI (Quality Assurance and Performance Improvement) program. "It should be." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 Facility ID: CA240000058 If continuation sheet 9 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056053 (X3) DATE SURVEY COMPLETED 01/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAVEN POST ACUTE 1311 E Date St San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of he facility policy and procedures titled "Abuse" undated, indicated ..." The facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. The facility promptly reports and thoroughly investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation, of resident property, or injuries of an unknown source, and suspicions of crimes ... "Money and other valuables should be taken to the business office for safe keeping ..." During a review of the facility's policy and procedure titled, "Theft and Loss" dated revised July 11, 2017 indicated under "Policy" the "The facility is committed to preventing the misappropriation of resident property. The facility investigates all reports of stolen items, reports to authorities as required by law, and maintains documentation of all reports of loss or stolen property." Under the section titled "III A. The investigation may consist of the following: i An interview with any individual who may have knowledge of the items , including facility staff on all shifts. ii An interview with the resident. iii An interview with the person (if any) accused of taking the resident;'s property iv. A review of the resident's inventory record to determine if the missing items were recorded. v. Interviews with residents' roommate, family members and visitors. vi. Search of laundry and/or kitchen for missing items." A review of the Theft and Loss logs for Residents A, B, C, D, E, F, G, H, I, J and K indicate the residents room and /or wheelchair was searched. There is no evidence of staff, roommates, or family remembers being interviewed as per the facility policy for theft and loss. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 Facility ID: CA240000058 If continuation sheet 10 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056053 (X3) DATE SURVEY COMPLETED 01/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAVEN POST ACUTE 1311 E Date St San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE There was no documented evidence that the facility had reported this criminal activity to law enforcement or to the California Department of Public Health as required, or had investigated thoroughly the allegations from Residents A, B,C, D, E, F, G, H, I, J and K about their missing cash and/or debit cards being used by staff. There was no documented evidence of the facility trying to identify a pattern of staff or other personnel who had contact with the residents at the time the money was found to be missing, to determine who might be responsible to prevent further theft and loss, and emotional abuse for these residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 Facility ID: CA240000058 If continuation sheet 11 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056053 (X3) DATE SURVEY COMPLETED 01/14/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAVEN POST ACUTE 1311 E Date St San Bernardino, CA 92404 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9FL011 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA240000058 (X5) COMPLETE DATE If continuation sheet 12 of 12