Inspection Reports for
Waterman Canyon Post Acute

The complaint involved Resident 1 who was transferred to the hospital after aggressive behavior and a 5150 psychiatric hold. The facility did not permit the resident's return despite psychiatric clearance, violating their own policies. The Director of Nursing and Marketing Coordinator confirmed the refusal was due to safety concerns for other residents. The complaint was substantiated with findings of policy noncompliance.

The facility failed to allow Resident 1 to return after hospitalization despite psychiatric clearance, resulting in delayed transfer to a skilled nursing facility and potential emotional distress. The facility's policies on bed-holds and returns were not followed, and the Director of Nursing acknowledged not accepting the resident back due to safety concerns for others.

The complaint investigation found that Resident 1 was transferred to a lower level of care without including the Ombudsman in discharge planning, and Resident 2 was transferred to another facility's dementia unit without involving the conservator or Ombudsman. The facility did not have integrated discharge team meetings documented, and notifications to family or representatives were inconsistent. The conservator for Resident 2 was contacted but did not respond, and the Ombudsman was notified only after discharge.

The facility failed to ensure safe transfer and discharge procedures for Residents 1 and 2, both with cognitive impairments, by not including the Ombudsman or conservator appropriately in discharge planning. Residents were transferred without capacity to understand or make decisions, and notifications to family or representatives were incomplete or delayed.

The complaint involved an allegation of physical abuse between Resident #29 and Resident #83. The facility reported the incident to the state survey agency on 03/17/2025 at 10:58 AM, which was not within the required two-hour timeframe. The Assistant Director of Nursing stated the facility reported incidents without major injury within 24 hours, contrary to their policy requiring reporting within two hours.

The facility failed to report an allegation of resident-to-resident abuse within the required two-hour timeframe as per their policy. Additionally, the facility failed to ensure resident rooms met the minimum required square footage per resident.

The facility failed to assist two of three sampled residents with activities of daily living, resulting in Moisture-Associated Skin Damage (MASD) for Resident 1. Additionally, call lights were improperly positioned, limiting residents' ability to summon assistance.

The investigation was complaint-driven, focusing on allegations of neglect in diaper changing and call light accessibility. The complaint was substantiated as failures were confirmed through interviews and record reviews.

The facility staff failed to assist with activities of daily living for 2 of 3 sampled residents, resulting in Moisture-Associated Skin Damage (MASD) for Resident 1 and improper call light placement affecting Resident 2. These failures posed risks to residents' health and safety.

The visit was complaint-related due to allegations that CNA 1 used profanity towards Resident 3 during an activity program. The complaint was substantiated as the facility confirmed the incident and terminated CNA 1's employment.

The facility failed to ensure Resident 3 was treated with respect and dignity when CNA 1 used offensive language directed at him, violating his rights and causing potential psychosocial harm. CNA 1 was terminated for violating company policy, and the facility's policies on resident rights and staff conduct were not followed.

The complaint was substantiated. CNA 1 used profanity directed at Resident 3 during an activity program. The facility terminated CNA 1's employment for violation of company policy. The Walk Away Policy was not followed by CNA 1.

The facility failed to ensure Resident 3 was treated with respect and dignity when CNA 1 used offensive language directed at the resident. The facility terminated CNA 1's employment for violating company policy and failing to follow the Walk Away Policy.

The complaint investigation found that Resident 3 was left unsupervised during a shower on March 9, 2024, leading to new blisters. The CNA assigned to Resident 3 left the resident alone multiple times, contrary to facility policy. The complaint was substantiated based on interviews and record reviews.

The facility failed to ensure adequate supervision of Resident 3 during a shower, resulting in multiple blisters from prolonged exposure to hot water. The facility did not follow its own policies requiring staff to stay with residents needing assistance during bathing.

The facility failed to properly collect and document a 24-hour urine specimen for one of three sampled residents, resulting in the resident not completing a physician-ordered laboratory test. Documentation was incomplete regarding collection times, assessment of urine, and laboratory results, and there was confusion about the collection container and order timing.

The complaint investigation found that the facility did not report a fall resulting in a fracture for Resident 1 as required. The facility determined the fall was witnessed and not unusual, thus not reportable, but this was contrary to policy. The deficiency was substantiated with minimal harm and few residents affected.

The facility failed to report the fall and subsequent fracture of Resident 1 to the state agency, despite the incident meeting criteria for reporting. Interviews with the Assistant Director of Nursing and Administrator revealed the facility did not consider the event an unusual occurrence and thus did not report it, contrary to their policy requiring reporting within 24 to 48 hours.

The complaint investigation found that the facility did not substantiate proper response to a resident's change of condition as reported by the resident's family. The failure to assess and notify the physician was confirmed through interviews with the Licensed Vocational Nurse, Assistant Director of Nursing, and Director of Nursing.

The facility failed to assess, document, and notify the physician about a clinically compromised resident's change in condition, resulting in delayed treatment. Interviews with nursing staff confirmed the lack of documentation and failure to initiate a Change of Condition despite family notification.

The complaint was substantiated by the Assistance Director of Nurses. The incident involved physical abuse by CNA 1 against Resident 3. The employee was terminated and reported to the California Department of Public Health. Resident 3 declined psychologist follow-up but services remain available.

The facility substantiated the allegation of physical abuse by CNA 1 against Resident 3. The staff member was immediately removed, placed on administrative suspension, and subsequently terminated. Resident 3 was assessed with minor swelling and headache but showed no visible distress or fear. The facility initiated an investigation, notified authorities, and scheduled staff in-service training on resident abuse.

The complaint investigation found that Resident 1, who did not have the capacity to make decisions, was allowed to leave the facility against medical advice without notifying the police, ombudsman, or adult protective services. The discharge was unsafe and not properly documented or reported as required by facility policy.

The facility failed to notify the police, ombudsman, and adult protective services when Resident 1, who lacked capacity to make decisions, left against medical advice. This resulted in an unsafe discharge for the resident.

The complaint investigation found that Resident 1 eloped from the facility multiple times due to inadequate supervision. The facility failed to document who picked up the resident or the resident's destination. Staff interviews confirmed the incident and lack of documentation. The elopement protocol was not properly followed.

The facility failed to prevent elopement of Resident 1, who was aggressive and left the facility multiple times. Staff called 911, but there was no documentation of who picked up the resident or where the resident was taken. Interviews with staff confirmed the lack of proper documentation and incomplete adherence to elopement protocols.

The facility had multiple deficiencies including environmental issues, inaccurate assessments, incomplete care plans, medication administration errors, infection control lapses, call light malfunctions, inadequate pest control, and kitchen sanitation problems.

The complaint investigation found that three residents were transferred to a sister facility five hours away based on insurance decisions without proper notification to the Ombudsman or resident representatives. Residents agreed to transfers after being approached by the Administrator from the sister facility.

The facility failed to ensure proper transfers for three sampled residents, initiating transfers based on the insurance company's decision without notifying the Ombudsman or discussing with residents' representatives. This placed residents at risk of isolation from family and friends.

The facility failed to ensure proper transfer procedures for three residents who were transferred based on the insurance company's decision without adequate notification to the Ombudsman or discussion with residents' representatives, placing residents at risk of isolation from family and friends. The residents agreed to the transfers after being approached by the Administrator of the sister facility.

The visit was complaint-related due to reports from residents and Resident Council Minutes about night shift staff not answering call lights promptly. The complaints were substantiated by interviews and record reviews showing delays of 30 minutes to over an hour in call light response.

The facility failed to ensure call lights were answered in a timely manner for two of three residents, resulting in one resident's fall and placing another at risk. Interviews and record reviews confirmed delays of up to an hour or more in responding to call lights, and care plans did not adequately address fall risks or call light usage.

The complaint was substantiated. Licensed Practical Nurse 1 did not follow the facility's infection control policy requiring residents exposed to COVID-19 to wear masks outside their rooms.

The facility failed to ensure that residents in isolation for possible COVID-19 exposure wore face masks when outside their rooms, increasing the risk of transmission. Licensed Practical Nurse 1 did not follow the infection control policy, as confirmed by interviews and observations.

The facility failed to ensure that a staff member (Licensed Practical Nurse 1) followed the facility's Infection Control Policy by allowing residents in isolation for possible COVID-19 exposure to be unmasked outside their rooms, increasing the risk of COVID-19 transmission. The Director of Nursing confirmed the staff member was not following policy despite being in-serviced.

The facility was found deficient in multiple areas including inaccurate medication coding in the MDS, failure to develop comprehensive care plans for certain medications, inadequate weight assessments, inappropriate pain medication administration, medication errors including late administration and exceeding acetaminophen dosage limits, improper medication storage and disposal, unlabeled food items, infection control lapses related to oxygen equipment and COVID-19 reporting, and insufficient resident room square footage.