Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laurel Convalescent Hospital during CMS and state inspections, most recent first.
A resident developed pressure injuries, including deep tissue injuries and open wounds, while in the facility. The facility failed to notify the resident's family about the new wounds and treatments. The resident was admitted without wounds, but they developed during the stay, contrary to the facility's policies on pressure injury prevention and family notification.
The facility failed to maintain the kitchen refrigerator temperature at the required 40 degrees Fahrenheit or lower, with observed temperatures reaching 45 and 49 degrees Fahrenheit. Staff interviews confirmed the risk of food-borne illness due to these elevated temperatures, which could affect all residents receiving food from the kitchen.
Two residents in the facility were found with unclean and untrimmed fingernails, despite their care plans requiring assistance with grooming. One resident, dependent on staff for all ADLs, had black and curled nails, while another, with moderate cognitive impairment, had long and dirty nails. Staff acknowledged the oversight, attributing it to communication lapses and the resident's recent admission.
A resident with a history of chronic kidney disease and urinary issues had an unsecured indwelling catheter, contrary to facility policy. Despite orders to secure the catheter every shift, an observation revealed the absence of a securement device. Staff interviews confirmed the expectation for securement, but the device was not in place.
The facility failed to follow its policy on timely response to call lights, affecting two residents. One resident reported long delays in receiving diaper changes, while another experienced waits of up to three hours for assistance. An observation confirmed that a call light went unanswered, with staff failing to check the call light panel as required by policy.
A resident with multiple health issues experienced the reopening of pressure injuries, indicating a failure in the facility's wound care policy. Additionally, a CT scan was ordered for the wrong foot, which could have delayed treatment for a suspected infection.
A resident with partial paralysis and dementia fell out of bed and was roughly handled by a CNA, who pulled the resident by one arm back onto the bed, causing the resident's hip to rub against the footrest. The CNA also verbally abused the resident by saying, 'Stop that! you're being annoying!' This incident was witnessed and overheard by multiple staff members. The facility's policy on abuse and mistreatment was not followed.
The facility failed to follow their policy when staff did not promptly notify the physician and alternative physician for a change of condition for a resident with a history of multiple medical conditions. Despite initial notification, no follow-up was made to contact an alternative physician or the Medical Director, resulting in a delay in treatment.
A resident with end-stage renal disease missed a scheduled dialysis session due to the facility's failure to arrange transportation. The resident was prepared and waiting, but the transportation service was unaware of the pick-up. The facility's policy on arranging transportation was not followed, leading to the missed treatment.
A resident with multiple diagnoses experienced a significant drop in blood sugar and oxygen levels. Despite the CNA reporting the resident's unresponsiveness and difficulty eating to the LVN, appropriate actions were not taken in a timely manner. The DON and Administrator confirmed a delay in treatment and lack of proper documentation and assessment.
The facility failed to document blood sugar results for a resident with type 2 diabetes mellitus, despite orders for regular checks and insulin administration. Inconsistent documentation practices and incorrect order input led to incomplete records in the MAR, as confirmed by nursing staff and the DON.
A resident with multiple serious diagnoses did not receive prescribed IV antibiotics upon admission due to the facility's failure to obtain the medications in a timely manner. The resident was sent back to the hospital at the request of the resident's daughter due to the unavailability of the IV antibiotics.
The facility failed to report an allegation of abuse involving a resident within the required timeframe. The incident, which occurred over a weekend, was not reported to outside agencies until two days later due to staff unawareness and miscommunication.
Failure to Prevent Pressure Injuries and Notify Family
Penalty
Summary
The facility failed to prevent the development of pressure injuries in a resident who was diabetic, obese, immobile, and at risk for skin breakdown. The resident developed deep tissue injuries on the left heel, left great toe, and first metatarsal, as well as a fluid-filled blister on the right medial foot. Additionally, the resident acquired open wounds on the left elbow and sacral area. The facility did not notify the resident's family about the left elbow and sacral open wounds and the wound treatment. The resident was admitted with no wounds, but the facility's records indicate that the wounds developed during the resident's stay. The Treatment Nurse acknowledged that the family was not notified and that follow-up calls should have been made. The Assistant Director of Nursing confirmed that the wounds developed in the facility and that the family was not notified. The facility's policies on pressure sore management and prevention of pressure injuries emphasize the importance of assessing residents for pressure injury risk factors and notifying families of changes in a resident's condition, which were not adhered to in this case.
Refrigerator Temperature Non-Compliance
Penalty
Summary
The facility failed to maintain the kitchen refrigerator temperature at 40 degrees Fahrenheit or lower, as required by their policy. During multiple observations on 11/11/2024, the refrigerator temperature was recorded at 45 degrees Fahrenheit and later at 49 degrees Fahrenheit. The Dietary Supervisor confirmed the temperature readings and acknowledged that such temperatures could impact food safety. The facility's policy clearly stated that the refrigerator temperature should be 40 degrees Fahrenheit or lower, yet the observed temperatures exceeded this limit. Interviews with facility staff, including the Dietary Supervisor, Regional Dietician, Director of Nursing, and Administrator, revealed a consensus that the refrigerator temperature should not exceed 41 degrees Fahrenheit to prevent food-borne illnesses. The Regional Dietician emphasized the risk of food-borne illness if the temperature remained at 45 degrees Fahrenheit for an extended period. The Administrator acknowledged the discrepancy between the observed temperatures and the facility's policy, which could potentially affect all residents receiving food from the kitchen.
Failure to Maintain Residents' Fingernail Hygiene
Penalty
Summary
The facility failed to ensure that the fingernails of two residents were clean and trimmed, as required by their care plans and facility policy. Resident #2, who has a history of dementia and cognitive impairment, was observed with black and curled fingernails. Despite being dependent on staff for all activities of daily living (ADLs), the necessary grooming was not provided. Certified Nurse Aide (CNA) #1 acknowledged noticing the issue weeks prior and reported it to a nurse, but no action was taken. Registered Nurse (RN) #3 confirmed that the resident's fingernails needed trimming and was unaware of the issue until it was brought to her attention. Resident #136, who has moderate cognitive impairment and requires assistance with personal hygiene, was also found with long and dirty fingernails. The resident expressed a desire to have their nails cut, but this had not been done since their admission. Restorative Nurse Aide (RNA) #5 and RN #3 both acknowledged the resident's nails were in need of care, and RNA #5 attributed the oversight to the resident being newly admitted. The Director of Nursing and the Administrator both stated that they expected residents' fingernails to be clean and trimmed regularly.
Failure to Secure Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident's indwelling catheter was secured with a securement device, as required by their policy. The policy, revised in August 2022, mandates that catheters remain secured to reduce friction and movement at the insertion site. Resident #52, who was admitted to the facility in July 2022, had a medical history that included chronic kidney disease, benign prostate hypertrophy, obstructive and reflex uropathy, and urinary tract infection. The resident's quarterly Minimum Data Set indicated moderate cognitive impairment and the presence of an indwelling catheter. An order from September 2024 directed staff to secure the catheter tubing with an anchor every shift to prevent dislodgement. During an observation in November 2024, it was noted that Resident #52's catheter was not secured with a securement device. Interviews with staff, including an LVN and the Director of Nursing, confirmed that a securement device should have been in place. The LVN was unaware of why the device was missing, while the DON emphasized the importance of having a leg band or anchor device for all residents with catheters. The facility's Administrator also stated that nurse aides were expected to verify the presence of the securement device every shift and notify the nurse if it was absent.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to adhere to its policy of answering resident call lights in a timely manner, which compromised the care of two residents. Resident 1, who was admitted with conditions including enterocolitis, muscle weakness, and hypertension, reported that it took hours for the nursing staff to change her diaper regardless of when she activated the call light. Similarly, Resident 2, who had a history of myocardial infarction, muscle weakness, and type 2 diabetes, stated that he sometimes waited up to three hours for assistance, and on occasions, staff would leave without providing the needed help and not return. During an observation, a call light was heard for an extended period without being answered. A Certified Nursing Assistant (CNA) claimed not to have heard the call light, attributing the sound to the Director of Staff Development (DSD) office. However, it was later confirmed that the sound originated from a resident's room. The DSD acknowledged that staff failed to follow the guidelines and policy, which required checking the call light panel to determine the source of the sound. This oversight in responding to call lights placed the residents' psychosocial health and safety at risk.
Pressure Injury Management and CT Order Error
Penalty
Summary
The facility failed to prevent the reopening of two pressure injuries for a resident, which placed the resident's health and safety at risk. The resident, who was admitted with conditions including contracture of the right knee, vascular dementia, and a flaccid neuropathic bladder, experienced a reopening of a Stage 4 coccyx wound and a Stage 3 left hip wound. Despite the facility's policy on pressure injury prevention, the resident's wounds reopened, indicating a lapse in the implementation of the policy. The facility's policy required regular assessment and repositioning of residents at risk for pressure injuries, but the reopening of the wounds suggests these measures were not effectively carried out. Additionally, there was a miscommunication regarding a physician's order for a CT scan. The order was incorrectly placed for the resident's right foot instead of the left, which was the site of concern for potential osteomyelitis. This error was acknowledged by the Assistant Director of Nursing and the Director of Nursing, who confirmed that the order was written for the wrong foot. The Treatment Nurse also noted that the right heel wound had resolved, and the focus was on the left heel, yet the CT order was not corrected before the resident was sent out, potentially delaying appropriate treatment.
Failure to Protect Resident from Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect Resident 1 from physical and verbal abuse. Resident 1, who had partial paralysis of the left side of the body following a stroke and dementia, fell out of bed. A Certified Nursing Assistant (CNA 1) pulled Resident 1 by one arm back onto the bed, causing the resident's hip to rub against the footrest. During this incident, CNA 1 verbally abused Resident 1 by saying, 'Stop that! you're being annoying!' This was witnessed by a Registered Nurse Supervisor (RNS) and overheard by a Minimum Data Set/Licensed Vocational Nurse (MDS/LVN 1) and a Licensed Vocational Nurse/Infection Preventionist (LVN/IP). The RNS had instructed CNA 1 to wait while she put on gloves, but CNA 1 did not comply and proceeded to handle Resident 1 roughly. The facility's Administrator, who was not in position at the time of the incident, reviewed the records and interviews and concluded that the facility had failed to protect Resident 1 from abuse. The facility's policy and procedure titled 'Abuse and Mistreatment of Residents,' dated May 3, 2023, was not followed. This policy outlines the prevention guidelines and procedures for reporting and addressing concerns of abuse, neglect, and mistreatment, which were not adhered to in this case.
Failure to Promptly Notify Physician for Change of Condition
Penalty
Summary
The facility failed to follow their policy when staff did not promptly notify the physician and alternative physician for a change of condition for one resident. The resident, who had a medical history including type 2 diabetes mellitus, osteoporosis, hypertension, rheumatoid arthritis, and muscle contracture of the left lower leg, experienced redness, swelling, and tenderness in the left foot. Despite the CNA alerting the nurse and the nurse assessing the resident, the physician was notified but did not respond, and no follow-up was made to contact an alternative physician or the Medical Director as per the facility's policy. The deficiency was identified during a review of the resident's records and interviews with the Registered Nurse Supervisor and the Administrator. The records showed that the physician was initially notified but did not respond, and the follow-up attempts were not made until much later, resulting in a delay in treatment. The facility's policy clearly stated that in the event of a change in condition, the physician should be called promptly, and if unreachable, an alternative physician or the Medical Director should be contacted. The Administrator acknowledged that the staff did not follow this policy, leading to a delay in addressing the resident's condition.
Failure to Provide Transportation for Dialysis Treatment
Penalty
Summary
The facility failed to ensure that a resident was provided transportation for his dialysis treatment appointment. The resident, who had a history of end-stage renal disease requiring hemodialysis, missed his scheduled dialysis session due to the facility's failure to arrange transportation. The resident was prepared for dialysis and waiting with paperwork and a sack lunch, but the transportation did not arrive. The CNA notified the charge nurse, and it was discovered that the transportation service was unaware of the scheduled pick-up. The dialysis center was contacted to reschedule the appointment for the following day, and the resident's medical director and family were informed. Orders were given to monitor the resident for fluid overload due to the missed dialysis session. During an interview, the Director of Nursing acknowledged that the resident should not have missed his dialysis treatment and that the staff should have called and notified the transportation services upon the resident's return from the hospital. The facility's policy and procedure on transportation, which states that social services will help residents obtain transportation as needed, was not followed. The Administrator confirmed that the staff did not adhere to the facility's policy, resulting in the missed dialysis treatment for the resident.
Failure to Properly Assess and Notify Physician of Change in Condition
Penalty
Summary
The facility failed to properly assess and notify the physician and responsible party of a change in condition for a resident, leading to a delay in treatment and transfer to an acute hospital. The resident, who had multiple diagnoses including encephalopathy, sepsis, type 2 diabetes mellitus, and MRSA, experienced a significant drop in blood sugar levels and oxygen saturation. Despite the CNA reporting the resident's unresponsiveness and difficulty eating to the LVN, appropriate actions were not taken in a timely manner. The CNA observed the resident's condition deteriorating during breakfast and lunch, noting that the resident was not staying awake and had to have food removed from her mouth. The CNA reported these observations to the LVN, who checked the resident's respirations but did not perform a full assessment or notify the physician. It was only after the resident's family expressed concern in the afternoon that the LVN took further action, resulting in the administration of glucagon and the calling of emergency services. Interviews with the DON and Administrator confirmed that there was a delay in treatment and a lack of proper documentation and assessment. The facility's policy on handling changes of condition was not followed, leading to a failure in providing timely and appropriate care for the resident. The deficiency was acknowledged by both the DON and the Administrator, who agreed that better assessment and documentation were needed.
Failure to Document Blood Sugar Results
Penalty
Summary
The facility failed to continually document blood sugar results in the medical record for a resident with multiple diagnoses, including type 2 diabetes mellitus. The resident was admitted with orders for regular blood sugar checks and insulin administration. However, the Medication Administration Record (MAR) for March and April 2024 lacked complete documentation of blood sugar results, and there was no clarification of a sliding scale for insulin administration. Interviews with various nursing staff revealed inconsistencies in documentation practices, with some nurses documenting results in progress notes instead of the MAR, and others noting the absence of a sliding scale in the orders. The Director of Nursing (DON) acknowledged that the order was input incorrectly, and parameters were not added, leading to the lack of documentation in the MAR. The facility's policy and procedure for obtaining a fingerstick glucose level and charting and documentation were reviewed, indicating that blood sugar results should be documented. Despite this, the resident's blood sugar results were not consistently recorded, and the admitting orders were not properly clarified. The Administrator confirmed the absence of documentation in the medical record for the resident, highlighting a significant lapse in tracking the resident's blood sugar patterns and results, which is crucial for managing diabetes effectively.
Failure to Administer IV Antibiotics as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received intravenous antibiotic medications as prescribed by the physician. The resident, who was admitted with multiple serious diagnoses including encephalopathy, sepsis, and MRSA, did not receive the prescribed IV antibiotics upon admission. The resident's medical records indicated that the antibiotics were to be administered daily, but the facility did not have the medications available until the day after the resident was admitted. This delay in treatment occurred despite the facility's policy that medications should be administered within one hour of their prescribed time. Interviews with the Registered Nurse Supervisor, Director of Nursing, and Administrator revealed that the facility did not receive the IV medications from the pharmacy in a timely manner. The resident was sent back to the hospital at the request of the resident's daughter due to the unavailability of the IV antibiotics. The facility's policy on administering medications was not followed, leading to a delay in the resident's treatment and placing the resident's health and safety at risk.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure staff reported an allegation of abuse to outside agencies within the timeframe specified by the facility's policy and federal regulations. Resident 1, who had diagnoses including heart failure, major depressive disorder, schizophrenia, and monoplegia of the upper limb, reported being hit by another resident on February 10, 2024. The incident was reported to a Licensed Vocational Nurse (LVN 1), who assessed the resident and sent her to the emergency room based on the physician's recommendation. However, the LVN did not inform the facility's abuse prevention coordinator or other relevant authorities about the incident immediately, as required by the facility's policy and federal regulations. The Social Worker (SW 1) confirmed that the incident was not reported to outside agencies until February 12, 2024, two days after the facility staff was made aware of the allegation. The delay occurred because the incident happened over the weekend, and the staff responsible for reporting and investigating abuse incidents were not present. The Director of Staff Development (DSD) acknowledged that the incident should have been reported immediately but cited miscommunication as the cause of the delay. A review of the facility's policies indicated that any suspicion of abuse must be reported immediately to the administrator and other officials according to state law. The policy defines 'immediately' as within two hours for allegations involving abuse or serious bodily injury, or within 24 hours for other allegations. The LVN involved stated she was unaware of the process for reporting abuse on weekends, which contributed to the delay in reporting the incident involving Resident 1.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 670 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fontana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citrus Nursing Center | 3.3 mi | — | 0 | 0 |
| Rialto Post Acute Center | 3.7 mi | — | 14 | 1 |
| Community Convalescent Center Of San Bernardino | 5.2 mi | — | 0 | 0 |
| Community Hospital Of San Bernardino Dp Snf | 5.2 mi | — | 2 | 0 |
| Shandin Hills Behavior Therapy Center | 6.8 mi | — | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Laurel Convalescent Hospital.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.