Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waterman Canyon Post Acute during CMS and state inspections, most recent first.
A cognitively intact resident with hemiplegia and hypertension requested an additional IDT care plan meeting from the SSD to clarify discharge planning after a prior care conference. Despite this request, the SSD acknowledged that the meeting had not been scheduled, and the ADON stated that an IDT member had forgotten to arrange it, even though it should have been scheduled. This inaction conflicted with facility policies that grant residents the right to participate in care planning, including requesting meetings, and to be informed of and involved in their care planning and treatment.
A resident with multiple medical conditions was not allowed to return to the facility after hospitalization, despite psychiatric clearance and facility policy requiring evaluation based on current condition. Staff did not assess the resident at the hospital and, following the DON's directive, refused readmission due to prior aggressive behavior, resulting in delayed transfer and possible disruption of care.
Two residents with cognitive impairments were transferred to lower levels of care or other SNFs without proper documentation of discharge planning, participation of legal representatives, or timely involvement of the Ombudsman. In both cases, required notifications and documentation related to resident needs and rights were incomplete or missing, despite facility policy requiring such actions.
Two residents with moderate cognitive impairment were involved in a physical altercation, with one resident striking the other after being awoken and punched. Staff intervened and notified the DON and emergency services, but the incident was not reported to the state survey agency within the required two-hour timeframe, as facility policy and regulations mandate.
Multiple rooms were found to provide less than the required 80 square feet per resident, with measurements showing shared rooms ranging from 71.29 to 78 square feet per resident. Staff and the DON acknowledged the room sizes did not meet regulatory standards, although CNAs reported the rooms were workable and no issues had been formally raised.
Two residents experienced deficiencies in care due to staff inaction. One resident developed Moisture-Associated Skin Damage (MASD) due to insufficient diaper changes, while another was unable to access her call light, which was improperly placed under her bed padding. These failures highlight significant lapses in adhering to facility policies regarding ADLs and call light accessibility.
A resident's dignity was compromised when a CNA used profanity directed at them during an activity program. The resident, who has chronic obstructive pulmonary disease and hypertension, was capable of making decisions. The CNA's behavior violated the facility's policy on resident rights and the walk-away policy, which requires staff to avoid inappropriate conduct by stepping away when frustrated.
A resident with paraplegia was left unsupervised in the shower by a CNA, resulting in multiple blisters due to prolonged exposure to hot water. The facility's policy requires continuous supervision for residents needing assistance with ADLs, which was not followed.
The facility failed to properly collect and document a 24-hour urinalysis specimen for a resident with serious medical conditions, resulting in the resident not completing a physician-ordered laboratory test. There was a lack of communication and proper follow-up among staff, and the facility did not adhere to its policy and procedure for urine specimen collection.
Failure to Timely Schedule Requested Care Plan Meeting for Cognitively Intact Resident
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to participate in the development and implementation of her person-centered plan of care by not timely scheduling a requested care plan meeting. The resident was admitted with diagnoses including hemiplegia and hypertension, and a recent Quarterly MDS showed a BIMS score of 14, indicating she was cognitively intact. An IDT care conference had been held on January 21, 2026, during which the team discussed her admission diagnoses, medications, psychosocial assessment, physical therapy, and discharge planning with her. On January 28, 2026, the resident requested another care plan meeting from the Social Service Director to obtain clarification regarding her discharge planning. By the time of the surveyor interview on February 10, 2026, the resident reported she had not received any update about her request. The Social Service Director confirmed that the care plan meeting had still not been scheduled, despite the request having been made approximately two weeks earlier. The ADON stated that an IDT member had mistakenly forgotten to schedule the requested meeting, even though it should have been scheduled. Facility policies on care planning and resident participation state that residents have the right to participate in care plan development, including the right to request meetings, and that care plan meetings are to be scheduled at the best time for the resident and family, and that residents are to be informed of and participate in their care planning and treatment.
Failure to Permit Return of Hospitalized Resident After Psychiatric Clearance
Penalty
Summary
The facility failed to permit the return of a resident following hospitalization, despite clearance from a psychiatrist for transfer back to the facility. The resident, who had a history of acute kidney failure, liver disease, and peripheral vascular disease, was initially transferred to the hospital after displaying aggressive behavior toward other residents and staff, which resulted in a 911 call and a 5150 psychiatric hold. Hospital records indicated that after evaluation, the resident was not considered a danger to self or others and was cleared for return to the facility. However, facility staff, including the DON and Marketing Coordinator, confirmed that the resident was not evaluated at the hospital for return eligibility, and the decision not to accept the resident back was made based on prior behavior rather than current clinical status. Facility policy required that residents be evaluated based on their current condition at the time of potential return, not on the circumstances that led to their initial transfer. Despite this, the DON instructed staff not to accept the resident back, citing concerns for the safety of other residents due to the resident's previous aggressive actions. The facility's failure to follow its own policies and procedures regarding bed-holds and return evaluations resulted in the resident's delayed transfer to another skilled nursing facility and possible disruption of care.
Failure to Ensure Proper Notification and Involvement in Resident Transfers
Penalty
Summary
The facility failed to ensure safe and compliant transfer and discharge processes for two residents with cognitive impairments. In the first case, a resident with a history of dementia, behavioral disturbances, and episodes of aggression was transferred to a lower level of care (Room and Board) and later to another skilled nursing facility (SNF) without proper documentation of the resident’s or family’s participation in discharge planning. The records showed inconsistent assessments of the resident’s capacity to make decisions, and there was no evidence that the Ombudsman was involved in the discharge process, despite the resident’s inability to sign notifications and the family’s lack of involvement. Additionally, there was no documentation of an interdisciplinary team (IDT) meeting regarding the transfer planning. In the second case, another resident with schizoaffective disorder, cognitive communication deficits, and a public guardian as conservator was transferred to a dementia unit at another facility. The conservator was only notified via voicemail, and there was no documentation of a response or participation in the discharge planning. The Ombudsman was not involved prior to the transfer, and the notification was sent only after the resident had been discharged. The facility staff acknowledged that the conservator was responsible for medical decisions but proceeded with the transfer based on safety concerns without documented consent or involvement from the conservator or Ombudsman. Both cases demonstrated a lack of required documentation and notification related to the residents’ needs, appeal rights, and bed-hold policies. The facility’s own policies require resident or representative participation in discharge planning, proper notification, and documentation of the reasons for transfer or discharge. However, the records reviewed did not show evidence of these requirements being met, particularly regarding the involvement of legal representatives and the Ombudsman for residents lacking capacity to make their own decisions.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident physical abuse to the state survey agency within the required two-hour timeframe, as specified by both facility policy and regulatory requirements. The incident involved two residents, both with moderate cognitive impairment and complex medical and psychiatric histories. One resident reported being awoken by another resident shaking their bed, followed by being punched on the thigh. In response, the resident struck the other on the head. Staff intervened, moved one resident to another room, notified the Director of Nursing, and called 911. Despite the facility's policy requiring immediate reporting of abuse allegations within two hours, the Assistant Director of Nursing reported the incident to the state survey agency the following day, outside the required timeframe. The ADON stated that incidents without major injury were reported within 24 hours, which contradicted the facility's written policy. Documentation confirmed the delay in reporting, and the incident was not communicated to the state agency as required.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum square footage per resident, as specified by federal and state regulations and the facility's own policy. Multiple rooms, including Rooms 101 through 107, 108, 109, 112, 114, 116, 202, 404, and 406, were measured and found to provide less than 80 square feet per resident in shared rooms. Specific measurements showed that rooms with three residents provided between 71.29 and 75.19 square feet per resident, and rooms with two residents provided between 73.48 and 78 square feet per resident, all below the required standard. The Director of Nursing and Maintenance Director both acknowledged that these rooms did not meet the regulatory requirements for space. During interviews, CNAs reported that while some rooms seemed small, they were still workable and comfortable for providing care, with staff able to move furniture as needed to facilitate movement. The DON stated that no issues related to room size had been reported by staff or residents, and that the facility conducted regular rounds to address room concerns. Despite these practices, the deficiency was identified based on direct observation and measurement of the rooms, confirming non-compliance with the required room size standards.
Failure to Assist with ADLs and Inadequate Call Light Access
Penalty
Summary
The facility staff failed to assist with activities of daily living (ADL) for two residents, leading to significant health issues. Resident 1, who was admitted with a diagnosis of a tear of the lateral meniscus, experienced Moisture-Associated Skin Damage (MASD) on the buttocks due to inadequate diaper changes. The resident reported that staff did not change her diaper throughout the night, and her call light was ignored. The Assistant Director of Nursing confirmed that Resident 1 received only three diaper changes over a 24-hour period on specific dates, which may have contributed to the MASD. Resident 3, admitted with muscle wasting and atrophy, was unable to access her call light, which was found secured beneath her bed padding. This placement prevented her from requesting assistance, as she was unaware of its location and unable to reach it. A Certified Nursing Assistant admitted to mistakenly placing the call light under the padding while tidying the bed. The facility's policy requires that call lights be within easy reach of residents, which was not adhered to in this case.
Resident Dignity Compromised by CNA's Use of Profanity
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during an activity program. A Certified Nursing Assistant (CNA) used profanity directed at the resident, which compromised the resident's dignity and violated their right to respect. The incident occurred during an activity program where the CNA told the resident to "F**k off" and repeated the phrase when the resident sought clarification. This behavior was witnessed by an Activity Assistant who reported it to the Assistant Director of Nursing. The resident involved in the incident was admitted to the facility with diagnoses of chronic obstructive pulmonary disease and hypertension. The resident was capable of understanding and making decisions, as indicated in their medical records. The use of profanity by the CNA was unprovoked and directed specifically at the resident, causing the resident to feel upset and disrespected. The facility had a policy in place requiring staff to walk away from situations where they become frustrated, to prevent inappropriate conduct. However, the CNA did not adhere to this policy, resulting in the incident. The facility's policy on resident rights, which mandates treating residents with kindness, respect, and dignity, was not followed in this case.
Failure to Provide Adequate Supervision During Shower
Penalty
Summary
The facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents during showering. Resident 3, who has paraplegia and muscle weakness, was left unsupervised in the shower by CNA 1. Despite Resident 3's preference for privacy, the facility's policy requires that residents who need assistance with ADLs be supervised throughout the shower. CNA 1 left Resident 3 alone multiple times, each for 8-10 minutes, to attend to other patients, which led to Resident 3 sustaining multiple blisters on his lower body due to prolonged exposure to hot water that he could not feel due to his condition. Resident 3's clinical records indicated that he required partial or moderate assistance with showering and was at risk for ADL/mobility decline due to his non-ambulatory status and paraplegia. On March 10, 2024, the Wound Care Nurse discovered new blisters on Resident 3's left leg, scrotum, and penis, which were attributed to the hot water exposure during the unsupervised shower. The Treatment Nurse confirmed that Resident 3 had informed her about the incident, and the physician was contacted to obtain a treatment order for the blisters. Interviews with the ADON and CNA 1 revealed that CNA 1 was unaware of the facility's policy requiring continuous supervision during showers for residents needing assistance. The facility's policy, revised in March 2024, clearly states that staff should stay with residents throughout the bath or shower and never leave them unattended. The ADON acknowledged that the facility did not follow this policy, leading to the incident where Resident 3 sustained injuries due to inadequate supervision during his shower.
Failure to Properly Collect and Document 24-Hour Urinalysis Specimen
Penalty
Summary
The facility failed to properly collect and document a 24-hour urinalysis specimen for one resident, who was clinically compromised and unable to complete a physician-ordered laboratory test. The resident, who had been admitted with serious conditions including malignant poorly differentiated neuroendocrine tumors, secondary malignant neoplasm of bone, spinal stenosis, and was under palliative care, required a 24-hour urine collection. Despite obtaining a new order to insert a Foley catheter for the urine collection, there was no documentation in the electronic medical record regarding the start and end times, or any assessment of the urine collection. Additionally, no laboratory results were available for the ordered test. Interviews with staff revealed that there was a lack of communication and proper follow-up regarding the urine collection order. The Case Manager was unaware of the nurse's progress note about the 24-hour urine collection order, and the Assistant Director of Nursing confirmed that there were no orders from the resident's oncology visit to collect urine. The resident's sister had informed the nurse about the collection, but the facility did not follow the proper procedure for handling the collection container. The facility's policy and procedure for 24-hour urine specimen collection were not adhered to, leading to the failure in completing the physician-ordered test for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Bernardino
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Healthcare Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Medical Center Convalescent Hospital | 0.4 mi | ★★★★★ | 13 | 0 |
| Arrowhead Springs Healthcare | 0.5 mi | ★★★★★ | 0 | 0 |
| Haven Post Acute | 1.3 mi | ★★★★★ | 1 | 0 |
| Del Rosa Villa | 1.7 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.