Health inspection·March 21, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview, record review, and facility document and policy review, the facility failed to report an allegation of resident-to-resident abuse involving 2 (Resident #29 and Resident #83) of 2 sampled residents reviewed for abuse to the state survey agency within two hours. Findings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 04/2021, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations). The policy specified, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknow source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy further specified, 3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #29's admission Record revealed the facility admitted the resident on 12/19/2024. According to the admission Record, the resident had a medical history that included diagnoses of muscle wasting and atrophy, abnormality of gait and mobility, adult failure to thrive, dehydration, weakness, atherosclerotic heart disease, alcohol abuse, acute on chronic diastolic congestive heart failure, cand essential hypertension. Resident #29's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/30/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not exhibit any physical or verbal behavioral symptoms directed towards others during the seven-day assessment look-back period. Resident #29's Care Plan Report included a focus area, initiated 12/24/2024 and revised 01/01/2025, that indicated the resident had cognitive loss, impaired decision-making skills ,and forgetfulness and needed verbal reminders. Resident #83's admission Record revealed the facility admitted the resident on 04/09/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, bipolar type; Parkinsonism; delusional disorders; hallucinations; major depressive disorder; insomnia; and muscle wasting and atrophy. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 055565 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 03/21/2025 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)