Waterman Canyon Post Acute

Inspectors wroteBased on interview and record review, the facility failed to honor one of three sampled residents' (Resident 1) right to participate in the development and implementation of his or her plan of care when Resident 1's request for a care plan meeting was not addressed and scheduled by the facility in a timely manner. This failure had the potential to cause Resident 1 not to receive the needed care and services to meet their care planning goals.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a safe transfer and discharge for 1 of 3 sampled residents (Resident 1 and 2) when: 1. Resident 1 history of dementia was transferred to a lower level of care Room and Board, and Ombudsman not included in discharge planning. 2. Resident 2 was transferred to another facility dementia unit without Conservator and Ombudsman included in discharge planning. This failure resulted in Residents 1 and 2 being transferred without capacity to understand and make decisions, not being informed of rights regarding transfer/discharge and the added protection of the Ombudsman (patient rights advocate who ensures residents are not inappropriately discharged ).

Inspectors wroteBased 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.

Inspectors wroteBased on interview, observation, and facility policy review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in Rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 112, 114, 116, 202, 404, and 406.

Inspectors wroteBased on observation, interview and record review the facility staff failed to assist with activity of daily living (ADL) for 2 of 3 sampled Residents (Resident 1 and 3). This failure led to Resident 1 experiencing Moisture-Associated Skin Damage (MASD), characterized by skin inflammation and erosion due to extended exposure to moisture sources such as urine or stool. These failures posed a significant risk to the psychosocial well-being, health, and safety of both clinically compromised Residents 1 and 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) was treated with respect and dignity when a Certified Nursing Assistant (CNA 1) used profanity (language that is rude, offensive, or vulgar, often involving swear words, or disrespectful terms) with Resident 3 during an activity program on November 12, 2024. This failure compromised Resident 3 ' s dignity and violated his right to respect, which had the potential for Resident 3 to experience psychosocial harm (mental harm and suffering).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accident during shower for one of three sampled residents (Resident 3), when Resident 3 was left in the shower unsupervised. This failure resulted in Resident 3 to receive multiple blisters to his lower body area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly collect and document for one of 3 sampled residents (Resident 1) a 24-hour urinalysis specimen. This failure contributed to a clinically compromised Resident 1 not completing a physician ordered laboratory test.

Inspectors wroteBased on interview and record review, the facility failed to report an unusual occurrence for one of 3 sampled residents (Resident 1) per there policy and procedure to the California Department of Public Health (CDPH) for a fall that resulted in right femur fracture. This failure has the potential to put (Resident 1) a clinically compromised resident health, safety, and well-being at risk.

Inspectors wroteBased on interview and record review the facility failed to follow their change of condition policy when one of three sampled residents, Resident 1 ' s daughter notified a license nurse of her Mothers (Resident 1 ' s) shortness of breath and stomach pains. This failure had placed a clinically compromised Residents (Resident 1) health and safety at risk by causing delay in treatment when no assessment, no documentation, and no physician notification, was done on a change in condition.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe and abuse free environment for one of three sampled resident (Resident 3) when Resident 3 was hit in the face by CNA 1 on November 26, 2023. This failure had the potential to cause emotional distress that could affect Resident 3's highest practicable level of psychosocial health and well- being.

Inspectors wroteBased on interview and record review the facility failed to follow their policy when one of three residents (Resident 1) was allowed to leave the facility and the appropriate agencies (police, ombudsman, and adult protective services) were not notified of this discharge. Resident 1 did not have the capacity to make her own decisions. This failure resulted in a unsafe discharge for a confused resident (Resident 1).

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a sanitary kitchen when: 1. The liners, inside the drawers and cabinets, were painted over, and was lifting and had a sticky residue underneath. 2. A green bucket, containing black water, and a sponge was stored in a cupboard under the sink. 3. There were black dirt, trash, and food residue on the floor, under the stove. There were yellow debris on the wall behind the stove. 4. There was an accumulation of leftover food in the gap between the floor and the stainless-steel island (isolated workstation/table in the kitchen area, away from the walls). 5. The liners on the closet drawers and drawers near dry storage were not smooth and not easy to clean. 6. The cabinets and drawers on the wall, near the dishwasher, had peeling linings. The drawers were sticky and not smooth and had debris. 7. [...]

Inspectors wrote5.a. During a review of Resident 55's clinical records, the admission Record, indicated Resident 55 was admitted on [DATE], with diagnoses which included hypertension (elevated blood pressure), neuralgia (nerve pain caused by inflammation, injury, or infection) and malaise (general feeling of discomfort). During a review of Resident 55's physician's order, dated February 22, 2018, it indicated, Morphine Sulfate ER (controlled medication used for pain) Tablet Extended Release 15 MG, give 1 Tablet by mouth every 12 hours for Pain Management . During a concurrent observation and interview with a LVN 2, on June 8, 2023, at 6:10 AM, LVN 2 inspected the bubble pack (a card that packages doses of medications within plastic bubbles organized by day and time of the day) containing Resident 55's Morphine Sulfate ER 15 MG tablets. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition, when: 1. Eight dish racks had cracks and chips. 2. One ice chest had a crack and hole in the bottom of the outer corner. These failures can lead to nests of pathogenic microorganisms, insects, and rodents, affecting 158 highly susceptible residents who receives food from the kitchen.

Inspectors wrote3. During an observation and interview with Resident 39, on June 7, 2023, at 8:09 AM, in Resident 39's room, Resident 39 was lying in bed, with the head of the bed elevated, eating breakfast. Resident 39 stated she needed a cup to pour her drink and pushed the red button at the end of the call light cord, to call for assistance. The call light indicator, above the door of room [ROOM NUMBER], did not turn on. During a concurrent observation and interview, on June 7, 2023, at 8:11 AM, with the Certified Nursing Assistant (CNA 4) in room [ROOM NUMBER], the CNA 4 inspected the call light for bed A, and it was inoperable. CNA 4 stated she was aware of the light not working for room [ROOM NUMBER]'s doorway but she did not notify the nurse supervisor. CNA 4 further stated the light on the doorway was expected to be on, when residents press the red button requesting assistance from the staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and homelike environment when: 1. There was water damage found in the ceiling in one of 57 resident rooms (Resident 26's room). 2. A report for a missing personal belonging was not addressed in accordance with the facility's policy for one of two residents (Resident 14) reviewed for personal belongings. These failures had the potential to negatively affect the mental and emotional well-being of Residents 26 and 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set Assessment (MDS- a computerized assessment instrument) for one resident (Resident 89) reviewed for restraints (device used to prevent someone from doing something). This failure had the potential to cause inaccuracy in identifying Resident 89's care and support needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans (a summary of a resident's health conditions, specific care needs, and current treatments) were updated and revised for 3 of 5 residents (Residents 96, 17, and 28) reviewed for care planning when: 1. For Resident 96, a care plan was not developed when Resident 96 had a change in condition on June 4, 2023. 2. For Resident 17, a care plan was not developed when Resident 17 was admitted to hospice (specialized end-of-life care for all patients with a terminal illness with a prognosis of 6 months or less) on May 22, 2023. 3. For Resident 28, a care plan was not developed when Resident 28 was admitted to hospice on May 11, 2023. These failures had the potential for Residents 96, 17, and 28 to not receive care and services that were appropriate to the residents' current needs and goals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and document resident progress after a change in condition for one of three residents (Resident 88) reviewed for hospitalization when Resident 88 had change in condition on April 20, 2023. (Resident 88 had a decreased potassium [an essential mineral that helps the body's nerves to function and for muscles to contract] laboratory (lab) value.) This failure had the potential to result in the lack of coordination of care and monitoring for Resident 88 placing him at risk for an abnormal heart rhythm due to decreased potassium levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the post fall protocol was implemented in accordance with the facility's policy and procedure for one resident (Resident 17) reviewed for falls, when the Interdisciplinary Team (IDT - a group of healthcare professionals from different disciplines working towards a common goal for a resident) conducted a review of Resident 17's fall which occurred on May 7, 2023, 29 days after the incident, on June 5, 2023. This failure had the potential for Resident 17 to be at risk of further falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nutrition screening had the correct information for one of four residents (Resident 73) reviewed for nutrition. This failure had the potential for Resident 73 to be at risk for malnutrition (an unhealthy and unbalanced diet) and significant weight loss due to him not receiving the appropriate therapeutic diet (a diet ordered by a physician or other delegated provider that is part of the treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet, or to provide mechanically altered food when indicated) he needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 94) reviewed for antibiotics received antibiotic medication in accordance with the physician's orders. This failure resulted in Resident 94 to miss a prescribed antibiotic placing his health at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a secure storage of medications for one of nine medication carts (used by licensed nurses to transport medication to resident rooms)(Medication Cart) when Medication Cart 6 was unlocked while unattended by a licensed nurse. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 159 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served fresh and at an appetizing temperature for one of three residents (Resident 14) reviewed for dialysis (a treatment that cleans the blood of people with kidney failure). This failure resulted in Resident 14 to purchase her own less nutritious dinners approximately three times a week which had the potential to lead to malnutrition (an unhealthy and unbalanced diet) and significant weight loss.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of five residents (Resident 560) reviewed for hospitalization when Resident 560's change in condition and hospitalization were not documented in accordance with the facility's policy and procedure. This failure had the potential for inaccurate communication between health care professionals, which can lead to delays in treatment, follow-up evaluations, and treatment plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure coordination with contracted hospice (specialized end-of-life care for all patients with a terminal illness with a prognosis of 6 months or less) services was being implemented for two of four residents (Residents 17 and 28) reviewed for hospice when: 1. For Resident 17, there was no current hospice plan of care (specific written instructions ordered by a physician that specify the hospice care and services a resident will receive) for recertification period of May 22, 2023, to August 19, 2023, available in Resident 17's health records. 2. For Resident 28, there was no current hospice plan of care for recertification period of April 22, 2023, to June 20, 2023, available in Resident 28's health record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the possible spread of infection during and after care on residents under contact precautions (used when a patient has an infectious disease that may be spread by touching other objects the patient has handled) when: 1. Two Certified Nurse Assistant (CNA 1 and 2) did not wash their hands with soap and water, according to facility's policy, after contact with Resident 18 (a resident on contact precautions for C-difficile (bacteria that causes diarrhea and inflammation of the colon and can be transmitted from person to person by spores [resistant to alcohol-based hand rub]). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for two of fifty-seven residents' rooms (rooms [ROOM NUMBERS]), when small ants were found crawling in both rooms. This failure had the potential to cause skin irritation to residents and could spread infectious bacteria to 159 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required square footage (sq. ft.- the amount of space) for 15 of 57 resident rooms (Rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 112, 114, 116, 202, 404 and 406). This failure had the potential to limit the movement of the residents in their room and could adversely affect the health and safety of the facility's 159 residents.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to maintain a medication error rate of less than 5%. The medication error rate was 28.13%, when three random sampled residents (Residents 117, 63, and 67) received their prescribed medications which were to be administered at 9:00 AM during the afternoon medication pass on May 20, 2021. These failures had the potential to negatively impact the health and well-being of three of 155 residents in the facility receiving medications.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to ensure: 1. Internal and external (medication routes, i.e., oral medications, eye drops, injectable medication) medications were stored separately. 2. Proper Disposal of eight, prescription medication, bubble packs (cardboard medication holders with plastic bubbles containing medication) for five of 155 Residents per facility policy. These failures had the potential to increase medication errors and have medications available for inappropriate usage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure whole potatoes stored in a bin within the kitchen, were labeled with the date they were received at the facility. This failure had the potential for food available for resident consumption, to become outdated past its shelf-life which may lead to a deterioration of peak flavor (taste), texture, and appearance, and may also lead to food-borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement their infection control program by not following their policy and procedures when: 1. For one out of eight residents, (Resident 85) the oxygen tubing and oxygen humidifier bottle (a device which keeps the air moist) were not changed as per the facility's policy and procedure. This had a potential to place the resident at risk for bacterial infection, nasal ulcerations, and discomfort. 2. The facility failed to report to the dialysis clinic the status of their COVID-19 (an infectious respiratory ailment that can be fatal in compromised residents) residents. This had the potential for the three of eight Residents to expose patients at the dialysis unit to COVID-19.

Inspectors wroteBased on interview, and record review, the facility did not ensure accurate coding for aspirin in the Minimum Data Set (MDS - facility assessment tool) assessment for one of 155 residents (Resident 124) when it was coded as an anticoagulant (a drug used to inhibit clotting of blood). This failure resulted inaccurate documentation in the MDS assessment that potentially affect quality measure monitoring for the health and safety for Resident 124.

Inspectors wroteBased on interview, and facility record review, the facility failed to develop a comprehensive, person-centered care plan for Resident 78 when: 1. A care plan for prescribed antidepressants was not developed and implemented. 2. A care plan for prescribed narcotic pain medication was not developed and implemented. These failures had the potential to negatively impact the health and well-being of Resident 78 due to lack a of a person-centered care plan with treatment goals and interventions.

Inspectors wroteBased on interview, and record review, the facility failed to ensure body weight assessments were obtained and documented for one newly admitted resident (Resident 4) in the frequency specified in the facility's policy and procedures. This failure had the potential to result in a delay in the facility's ability to identify undesirable weight loss, and/or nutritional needs for Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain medication was provided consistent with professional standards of practice when medication intended for moderate to severe pain was given to a resident when there was no pain or only mild pain present. This had the potential to cause harm to the resident due to the risks for constipation, addiction, sedation and confusion.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the correct administration of acetaminophen (a drug used to treat minor pain and fever) medication should not exceed the maximum dose of 3 grams per day for one of 79 residents (Resident 110), who was receiving both acetaminophen and Norco (a narcotic pain medication which contains acetaminophen). This failure had the potential to result physical harm due to potential adverse effects related to excess use of acetaminophen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required square footage (sq/ft) for 14 resident rooms (room [ROOM NUMBER], 102, 103, 104, 105, 106, 107, 108, 109, 112, 114, 116, 202, and 404). This failure had the potential to limit the movement of the residents in their room and could adversely affect the health and safety of the residents in the above mentioned rooms.