Health inspection·April 13, 2024

F 0689 [specific area] for open blister . Level of Harm - Minimal harm or potential for actual harm During a review of Resident 3's clinical record titled IDT note [Interdisciplinary Team - a group of healthcare professionals from different disciplines working towards a common goal for a resident) dated March 12, 2024, it indicated Resident asked the CNA [Certified Nurse Assistant 1] to wheel him to the shower room. Resident prefers to take a shower privately and he wants only set up help. CNA turned on the shower to middle area. Then Resident asked for the shower head so he can take shower by himself. CNA left resident during shower. CNA came back to check if he is done and wheeled resident back to his own room. During treatment . noted Also a blister on mid upper thigh Resident had multiple scar tissues on sacrum and perineal areas upon admission. Per Treatment Nurse, the areas where tissues were peeled off were pink and no bleeding noted. But due to peeled off areas were open; they were at high risk for complications . Residents Affected - Few During concurrent observation and interview with Resident 3, on March 26, 2024, at 1:00 PM, Resident 3 sitting down in the wheelchair at the facility outside patio. Resident 3 stated I think I let the running shower head rest on my lap too long while washing my upper body not realizing the water might have been too hot for my skin, I can't feel anything from waist down. During further interview with Resident 3, on March 26, 2024, at 1:10 PM, Resident 3 stated CNA 1 was not with him throughout the shower. CNA 1 told him that he would come back to check on him and that he needed to attend to other patients. Resident 3 further stated CNA 1 was in and out the shower room approximately three times, each time being gone for 8-10 minutes. Resident 3 expressed he would feel safer and more comfortable if CNA 1 stayed with him throughout the shower. During an interview with the Treatment Nurse (TN), on April 19, 2024, at 11:25 AM, the TN stated that on March 10, 2024, during treatment, she discovered new blisters to left leg, scrotum, and penis area. She further stated that when she asked Resident 3 about it, he informed her that he had left the shower head running for too long yesterday (March 9, 2024). The TN then contacted the doctor to report the issue and obtain a treatment order. During an interview with Assistance Director of Nursing (ADON), on April 19, 2024, at 2:50 PM, the ADON stated CNA 1 should have stayed with Resident 3 throughout his shower to supervise for safety. During a follow up telephone interview, with CNA 1 on April 19, 2024, at 3:45 PM, CNA 1 stated that on March 9, 2024, Resident 3 was assigned to him for the first time. CNA 1 stated he wheeled Resident 3 to the shower room and adjusted the water temperature to be approximately between cold and hot, before leaving Resident 3 inside the shower room. CNA 1 further stated that he was unsure about the facility's practice, but he informed Resident 3 before leaving the shower room that he would be outside that he needed to attend to other patients and would check on him if he needed assistance or had finish his shower. During a review of the facility' s policy and procedure (P&P) titled, Activity of Daily Living (ADL's), Supporting revised March 2018, the P&P indicated Policy Statement. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently . including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055565 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055565 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterman Canyon Post Acute 1850 N. Waterman Ave. San Bernardino, CA 92404 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a concurrent interview and record review with on April 19, 2024, at 4:00 PM, with ADON, the facility's P&P titled, Bath, Shower/Tub revised March 2024, was reviewed, the P&P indicated, Purpose. The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. General Guidelines. 1. Be sure that the bath area is at a comfortable temperature for the resident. 2. Residents who require assistance with ADL's: a. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower 3. Use the emergency call signal for assistance, if needed . The ADON stated the facility did not follow the policy. Event ID: Facility ID: 055565 If continuation sheet Page 3 of 3