The violation occurred in September when the facility declined to take back Resident 1 after his hospital stay. According to inspection records, the director of nursing told investigators on September 23 that accepting the resident "would potentially endanger the safety of other residents, as he had potential to assault them."
"I didn't take him back, this is the first time we didn't follow our policy," the director told inspectors during a 3:00 PM interview.
The facility's own written policies required a different approach. The October 2022 policy on bed-holds and returns states that residents whom staff are concerned about permitting to return "are evaluated based on their current condition, not their condition when originally transferred."
Similarly, the facility's March 2025 policy on transfer or discharge notices specifies that if discharge is initiated after an emergency hospital transfer, "the reason for discharge is based on the resident's status at the time the resident seeks return to the facility."
No such evaluation occurred.
The marketing coordinator confirmed during an October 21 telephone interview that "the facility did not evaluate the resident at the hospital to determine if he was okay to return." She told inspectors: "Normally we do, but in this case, we did not."
The coordinator said she was following orders from the director of nursing, who had told her before she called the hospital on September 6: "We cannot have him back. He is throwing things at patients, and he is a danger to others."
When she spoke with hospital staff, the coordinator repeated this message: "I was just following what my DON told me. The director informed me we cannot have him back. He is throwing things at patients and is a danger to others."
Hospital records noted the facility's refusal, stating that the "previous SNF not taking patient back." The documentation also mentioned "leadership talking with [NAME] and ombudsman being called," indicating the hospital had to involve outside advocates after the nursing home's rejection.
The case forced hospital staff to expand their search for placement to Riverside and San Bernardino counties to find another facility willing to accept the resident.
When inspectors asked the director of nursing directly whether the facility's policies had been followed, she "did not provide a direct answer," according to the inspection report.
The facility's actions violated federal regulations requiring nursing homes to have written policies governing readmissions and to follow those policies consistently. The violation was classified as causing minimal harm or potential for actual harm to few residents.
Federal nursing home regulations are designed to prevent patient dumping, where facilities refuse to readmit residents after hospital stays to avoid caring for those with challenging behaviors or complex medical needs. The regulations require facilities to evaluate each situation based on the resident's current condition, not past incidents.
The director of nursing's admission that this was "the first time" the facility didn't follow its policy suggests the facility was aware of its obligations but chose to ignore them in this case.
The inspection found that Waterman Canyon Post Acute failed to ensure residents were readmitted according to established policies and procedures, creating a situation where a vulnerable resident was left without appropriate placement after his hospital treatment.
The marketing coordinator's statement that she was "just following what my DON told me" indicates the decision came from facility leadership, not from line staff unfamiliar with policies.
Hospital staff were forced to involve an ombudsman, a patient advocate who investigates complaints about nursing home care, after the facility's refusal to readmit the resident.
The case highlights how facilities sometimes prioritize operational convenience over regulatory compliance, even when their own policies provide clear guidance on how to handle complex readmission decisions.
Resident 1 ultimately required placement in a different county after Waterman Canyon Post Acute's refusal to conduct the evaluation required by its own policies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waterman Canyon Post Acute from 2025-09-23 including all violations, facility responses, and corrective action plans.