Waterman Canyon Post Acute

In the surveyor’s words

From the most serious findings on record at Waterman Canyon Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 9, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF755Jun 9, 2023

  45388 Based on observation, interview, and record review, the facility failed to ensure medications were administered according to the facility's policies and procedures (P&P) when: 1. A Colistimethate (antibiotic medication- used to treat infection) IV (Intravenous- administers fluids, medications and nutrients directly into a person's vein) was not administered to Resident 94 on May 18, 2023 as prescribed by the physician. 2. Glucophage (medication used to lower sugar level) and Insulin Regular Human Injection (medication used to lower sugar level) was not administered to Resident 148 on June 4, 2023, as prescribed by the physician. 3. Resident 68 was administered Docusate Sodium (a stool softener) without being assessed for loose stools (as directed by the physician order). 4. […]

• No harm, potential for more than minimal, patternF908Jun 9, 2023

  Based 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. Findings: During the tour of the kitchen, on June 6, 2023, at 8:57 AM, eight dish racks were observed to have cracks and chips. […]

• No harm, potential for more than minimal, patternF919Jun 9, 2023

  45388 Based on observation, interview, and record review, the facility failed to ensure the call systems were functional and accessible when: 1. The call systems for five out of ten resident showers (two in Shower room [ROOM NUMBER] [SR 3], two in Shower room [ROOM NUMBER] [SR 4], and one in Shower room [ROOM NUMBER] [SR 5]) were not accessible. 2. The call light indicator, above the door, did not turn on in room [ROOM NUMBER] (affecting Beds A, B, and C call lights). 3. For room [ROOM NUMBER] A, the call light cord (a cord connected to the wall and has a red button at the end to activate the corresponding call light in the hallway) was not functioning. 4. The call light indicator, above the door, did not turn on in room [ROOM NUMBER] (affecting Beds A, B, and C call lights). 5. […]

• No harm, potential for more than minimal, patternF622Jun 5, 2023

  Based on observation, interview, and record review, the facility failed to ensure a proper transfer for three of three sampled resident (residents 1, 2 and 3), who agreed to be transferred after they were approached by the Administrator from a [sister facility located five hours away], and the transfers were initiated based on the Resident' insurance company's decision about who should be transferred out without notification of the Ombudsman and before discussing with the residents representatives. This failure resulted in facility-initiated transfers for residents 1, 2 and 3 to a sister facility located five (5) hours away, placing Resident at risk for isolation from family and friends. Findings: 1. […]