Health inspection·September 23, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review , the facility failed to permit the return of one of four sampled residents (Resident 1) following the clearance provided by a psychiatrist for transfer back to the facility from hospitalization . This failure resulted in Resident 1's delayed transfer to a skilled nursing facility (SNF- a place for people recovering from a hospital stay to get medical care and rehabilitation.) possibly resulted in disruption of care, which may lead to emotional distress.A review of Resident 1's admission Record (a document containing clinical and demographic information data) indicated Resident 1 was initially admitted to the facility on [DATE] , with a diagnosis that included acute kidney failure ( kidneys suddenly stops working properly), liver dieses ( a condition that stops the liver from working properly), and peripheral vascular disease ( blood vessels outside the heart and brain narrowed, restricting blood flow).During an interview on September 23, 2025, at 12:34 PM, the Director of Nursing (DON) confirmed that Resident 1 has been transferred to the hospital and is currently not in the facility.During a concurrent observation and record review, September 23, 2025, at 12:38 PM, it was observed Resident 1 was not present at the facility and noted that his name was not included in the current list of residents at the facility.During a review of the facility progress notes, dated September 4, 2025, it was recorded that at 10:30 AM, Resident 1 displayed aggressive behavior toward other residents and staff. A 911 call was made, and law enforcement arrived at the facility. A 5150 psychiatric evaluation was subsequently ordered, resulting in the transfer of Resident 1 to the hospital at 3:02 PM, on September 4, 2025.During a review of an Order Summary, dated September 4, 2025, at 1:34 PM, the order indicated for a 7-day hold, covering the period from September 4, 2025, to September 11, 2025.During a review of Emergency Department, notes dated September 4, 2025, it was noted that Resident 1 arrived at ER via EMS on September 4, 2025, at 3:24 PM. It was indicated that Resident 1 requires admission to Medical/Surgical floor, and a psychiatric evaluation was required for safety and further management.During a review of Resident 1's hospital psychiatry consult dated September 5, 2025, the note stated, .Disposition back to [NAME] Canyon; patient [Resident 1] is declining any thoughts of self-harm or harm to others. Patient [Resident 1] is not endorsing auditory visual hallucinations; patient is not endorsing delusional thought process.During a review of Resident 1's Social Worker (SW) note dated September 6, 2025, the note stated, .SW received a call from CMA reporting [name of a staff] from [NAME] Canyon Post is reporting the patient is unable to return. @1048~This writer called [NAME] w/[NAME] Canyon Post reporting the patient is unable to DC back due to being picked up by PD on 9/4/2025 and being placed on a 5150 hold and being aggressive with another resident. The patient [Resident 1] has been a resident at [NAME] Canyon Post for 3 years.During a review of the Discharge Planning Progress Note, dated September 9, 2025,it has been noted that the anticipated discharge date for Resident 1 is scheduled for September 10, 2025. The discharge plan entails transfer to SNF. Additionally, the search for (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 2 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 09/23/2025 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)