Waterman Canyon Post Acute
Inspection Findings
F-Tag F0627
F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
placement has been expanded to Riverside and San [NAME] county. The note stated, . Previous SNF not taking patient [Resident 1] back. Also, the note mentioned, .leadership talking with [NAME] and ombudsman being called.During an interview on September 23, 2025, at 3:00 PM with the DON, the director emphasized that not accepting the resident would violate their policy. But, accepting him would potentially endanger the safety of other residents, as he had potential to assault them. The DON stated, I didn't take him back, this is the first time we didn't follow our policy. During a concurrent interview and
record review on September 23, 2025, at 3:10 PM, with the DON, the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, dated October 2022 was reviewed. The P&P indicated, .Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred. During a subsequent interview and record review on September 23, 2025, at 3:10 PM, with the DON, the facility's P&P titled Transfer or Discharge Notices, dated March 2025, was reviewed. The P&P indicated, . If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to
the facility (not at the time the resident was transferred to acute care). When the DON was asked if the facility's P&Ps were followed, the DON did not provide a direct answer.During a telephone interview on October 21, 2025, at 10:57 AM with the Marketing Coordinator (Coordinator) , she confirmed that the facility did not evaluate the resident at the hospital to determine if he was okay to return, she stated, Normally we do, but in this case, we did not. She also added, I was just following what my DON told me.
The director informed me we cannot have him back. He [Resident 1]is throwing things at patients and is a danger to others. The coordinator explained that prior to her call to the hospital on September 6, 2025, the DON had informed her, We cannot have him back. He is throwing things at patients, and he is a danger to others.
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If continuation sheet
Waterman Canyon Post Acute in San Bernardino, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in San Bernardino, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Waterman Canyon Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.