Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Arrowhead Healthcare Center, Llc during CMS and state inspections, most recent first.
A facility failed to follow infection control practices for residents on oxygen, with two residents found using unlabeled and undated nasal cannula tubing and humidifiers despite physician orders to change and date them weekly. Staff also handled Hoyer lift slings outside the laundry area, stored visibly soiled BP cuffs in EBP carts, and did not use required gown and glove PPE or perform hand hygiene during high-contact care for a resident on EBP.
Four-bed resident rooms 102, 105, 106, 107, and 112 were measured by the MS, DON, and surveyor and were found to provide less than the required 80 sq ft per resident after accounting for moveable wardrobe cabinets. The Administrator and ADON reviewed the calculations and agreed the rooms ranged from about 71 to 75 sq ft per resident. A facility list showed residents in these rooms used Hoyer lifts, wheelchairs, Geri chairs, and walkers, and the facility had no policy on minimum room square footage per resident.
A resident with ESRD, dialysis dependence, obstructive uropathy, and reflux uropathy had a suprapubic catheter with a urine-filled drainage bag that was not dated and not covered by a dignity bag, leaving it visible to anyone entering or passing by the room. The IP acknowledged dignity bags were unavailable, while the ADON and Admin stated urinary drainage bags should be covered to maintain privacy and dignity, and the facility policy required the drainage bag to be kept inside a holder.
Failure to Recheck and Document Low Blood Sugar Readings: A resident with DM and insulin orders had multiple blood sugar readings below 70 mg/dl, but nursing staff did not document the required repeat BS check after giving juice as ordered. The DON and ADON reviewed the MAR and clinical record and could not find evidence that the low BS readings were rechecked or documented as a progress note.
Low Air Loss Mattress Set Incorrectly: A resident with pressure ulcers and multiple chronic conditions was observed on a LAL mattress that was programmed to 350 lbs instead of the 70-80 lbs range ordered by the MD. An LVN confirmed the mattress was set incorrectly, and the DON stated LAL mattresses are supposed to be programmed per MD order to reduce pressure and help prevent pressure ulcers from worsening.
A resident with ESRD, dialysis dependence, obstructive uropathy, and reflux uropathy had a suprapubic catheter with orders for weekly bag changes and PRN irrigation with 60 cc NS. Staff found the drainage bag lying on the mattress between the resident’s legs with cloudy urine, sediment, and a foul odor, and it was not dated or positioned for proper drainage. The TAR showed no documentation that the bag had been changed or the catheter flushed as ordered, and the DON/ADON acknowledged the facility policy and physician orders were not followed.
Inaccurate Dialysis Access Assessment Documentation: Nursing staff documented bruit and thrill checks for a resident with ESRD who had a CVC in the chest, even though bruit and thrill are assessed on a fistula or shunt. The MAR showed repeated documentation by multiple RNs/LVNs, and the DON and ADON stated the order was inappropriate, never clarified, and staff were confused about how to assess the resident's dialysis access.
Metformin was not administered as ordered for a resident with Type 2 DM and a G-tube. An LVN crushed and gave the 500 mg dose via GT with water, then left without providing food, even though the pharmacy label and MD order both instructed to give the medication with food. The LVN acknowledged the error, and the ADON and Admin confirmed the order and facility P&P were not followed.
Call lights were not kept within reach for two residents. One resident with hemiplegia and hemiparesis had the call light on the floor beside the bed and could not reach it, while another resident with paraplegia, respiratory failure, contractures, and dementia had the call light wrapped around a feeding pump on a pole away from reach. Staff acknowledged both call lights were out of reach and that the facility policy required them to be within easy reach.
The facility did not have an RN onsite for at least eight hours on three separate days, leaving 58 residents without required RN oversight. The DON, the only full-time RN, was absent due to illness, and the part-time RN was not scheduled to cover the gaps, resulting in noncompliance with staffing regulations.
The facility failed to maintain an effective infection prevention and control program. The infection control policies were not reviewed annually, and staff did not follow disinfectant guidelines, risking the spread of infections. Additionally, housekeeping staff did not adhere to Enhanced Standard Precautions, failing to wear required PPE when cleaning designated rooms.
The facility failed to accurately code the RAI-MDS for four residents, leading to potential unmet care needs and inaccurate clinical records. Errors included incorrect documentation of hearing loss and hearing aid use, PASRR status, insulin administration, and the presence of an indwelling urinary catheter. The MDS nurse acknowledged these errors, and it was noted that the facility lacked a specific policy for RAI-MDS assessments.
The facility failed to maintain food safety standards, as the walk-in refrigerator and freezer temperatures were not monitored, a kitchen staff member worked without a hair net, and shelves in the refrigerator were dirty. These issues could lead to foodborne illness among the 49 residents served by the kitchen.
A cockroach was observed in the kitchen behind the steam table, indicating a failure in the facility's pest control program. The Dietary Supervisor acknowledged the non-compliance with the State Operations Manual, and the Infection Preventionist noted the infection control risks posed by cockroaches. The facility's pest control policy required reporting and action, but the recent Service Inspection Report lacked detailed documentation.
A facility failed to discuss and document advance directives for a resident, as evidenced by an incomplete POLST form and lack of an Advance Directive Acknowledgement form. Interviews with the DON, RNS, and SSD confirmed the absence of required documentation, contrary to facility policy.
Two residents were not provided with necessary beneficiary liability notifications, including estimated costs on the SNF ABN and timely NOMNC forms. The BOM acknowledged the errors, which left the residents uninformed about their financial responsibilities and rights to appeal.
A facility failed to provide written notification to a resident's representative about a transfer to the hospital. The resident, diagnosed with schizophrenia and metabolic encephalopathy, was transferred due to vomiting dark liquid. The representative was informed verbally, but no written notice was given, violating regulatory requirements.
A resident with existing pressure ulcers did not receive appropriate care as specified in their care plan and physician's orders. The resident's low air loss mattress was set to an incorrect pressure, and heel protectors were not applied while in bed. Additionally, the resident's weekly nursing summary inaccurately reported intact skin, failing to acknowledge a deep tissue injury. These deficiencies were confirmed by the DON, highlighting a failure to adhere to the facility's care planning and assessment protocols.
A resident at high risk for falls was found without a fall mat next to her bed, contrary to her care plan. Despite the facility's policy on fall prevention, staff were unaware of the missing mat, and the Director of Nursing confirmed it should have been in place to minimize injury risk.
The facility failed to provide adequate room size for residents in five rooms, each housing four residents, with measurements showing less than the required 80 square feet per resident. This deficiency was confirmed by the Maintenance Supervisor and Administrator, who acknowledged the potential risks of accidents and delays in emergency evacuations due to limited space for wheelchairs and Hoyer lifts. The facility also lacked a policy on minimum room size requirements.
The facility did not post daily staffing information in an area accessible to residents, affecting all 55 residents. The information was placed near the main entrance, which was inaccessible due to a locked door and restricted access behind the nurses' station. The DSD and DON confirmed the oversight, which contradicted the facility's policy requiring visibility to residents and visitors.
The facility failed to provide residents with easy access to the most recent survey results, as the binder was placed in a locked lobby area. This restricted access was confirmed by nursing staff and acknowledged by the Administrator, violating the facility's policy on residents' rights.
Infection control failures with oxygen equipment, contaminated supplies, and PPE use
Penalty
Summary
Safe infection prevention and control practices were not followed for two residents receiving supplemental oxygen. Resident 53 was admitted with acute respiratory failure with hypoxia, dependence on supplemental oxygen, and cerebral infarction, and had physician orders for oxygen at 4 L/min via nasal cannula or face mask continuously, with a humidifier applied, and for the nasal cannula or face mask, tubing, and humidifier to be changed weekly on Sunday and dated when changed. During observation, the resident was on oxygen with a humidifier attached, but the nasal cannula tubing and humidifier were unlabeled and undated. The Infection Preventionist verified the items were not labeled or dated, and the DON stated the physician order was not followed. Resident 21 was admitted with COPD, nonrheumatic aortic valve stenosis, and dependence on supplemental oxygen. The resident also had physician orders for oxygen at 4 L/min via nasal cannula or face mask continuously, with a humidifier applied, and for the nasal cannula or face mask, tubing, and humidifier to be changed weekly on Sunday and dated when changed. During observation, the resident was on oxygen with a humidifier attached, but the nasal cannula tubing and humidifier were unlabeled and undated. The Infection Preventionist verified this, and the DON stated the physician order was not followed for this resident either. The facility also failed to maintain sanitary handling of equipment and to follow infection control practices during resident care. Two Hoyer lift slings were observed hanging from the exterior bars outside the laundry room windows, and the Administrator stated the sling should not be outside and should be laundered inside the laundry room because it was an infection control and contamination concern. Two manual blood pressure cuffs were found visibly soiled with a white substance and lint in two Enhanced Barrier Precautions carts, and the DON confirmed the cleaning policy was not followed. For Resident 37, who had a G-tube, acute MI, hemiplegia, and a care plan requiring Enhanced Barrier Precautions due to a G-tube and history of ESBL and MRSA, staff performed high-contact care and G-tube care without wearing the required gown. In addition, a housekeeper removed gloves after leaving a room on Enhanced Barrier Precautions and did not perform hand hygiene before continuing work in the hallway.
Four-Bed Resident Rooms Were Below Required Square Footage
Penalty
Summary
The facility failed to ensure that five rooms, each housing four residents, met the minimum required square footage per resident. A review of the facility census dated April 6, 2026, identified Rooms 102, 105, 106, 107, and 112 as four-bed rooms. During a concurrent observation and interview with the Maintenance Supervisor and the DON, the rooms were measured and the dimensions were verified by the MS, DON, and surveyor using the facility measuring tape. Room 102 measured 185 inches by 237 inches, Room 105 measured 178.5 inches by 238 inches, Room 106 measured 184 inches by 238 inches, Room 107 measured 178 inches by 244 inches, and Room 112 measured 184 inches by 239 inches. The Administrator and ADON reviewed the measurements and calculated the square footage per resident for each room. After accounting for moveable wardrobe cabinets in the rooms, each room remained below the required 80 square feet per resident, with calculated space ranging from 71.25 to 74.84 square feet per resident. During interview, the Administrator was asked for the residents assigned to these rooms and which residents used wheelchairs, walkers, Hoyer lifts, and/or Geri chairs. A facility document titled List of 5 rooms who Have 4 Residents indicated that among the residents in these five rooms, four required Hoyer lifts, nine used wheelchairs, five used Geri chairs, and two used walkers. The facility did not have a policy and procedure regarding the minimum required room square footage per resident.
Visible Urinary Drainage Bag Not Covered
Penalty
Summary
Resident 4, who was admitted with diagnoses including ESRD, dependence on renal dialysis, obstructive uropathy, and reflux uropathy, had a suprapubic catheter in place during observation. The urinary collection bag connected to the catheter was observed to contain urine, was not labeled with a date, and was not concealed within a dignity bag, making it visible to anyone entering or passing by the room. Resident 4 stated the facility did not offer or provide a cover for the catheter drainage bag. During interview, the Infection Preventionist acknowledged the urinary collection bag was not labeled with a date and was not concealed within a dignity bag, and stated dignity bags were currently unavailable in the facility. The Assistant Director of Nursing stated all urinary collection bags should be covered with a dignity bag to maintain privacy and dignity. The Administrator and ADON reviewed the facility policy for Foley catheters, which stated urinary drainage is kept inside a urinary drainage bag holder, and the Administrator acknowledged the policy was not followed when Resident 4's urinary collection bag remained visible.
Failure to Recheck and Document Low Blood Sugar Readings
Penalty
Summary
Nursing staff failed to follow a physician’s order for hypoglycemia management for Resident 43, a resident with type 2 diabetes mellitus, hemiplegia and hemiparesis, and a history of cerebral infarction. The physician’s order dated June 1, 2024 directed staff to give 4 ounces of juice when the resident’s blood sugar was 0-70 mg/dl and to recheck the blood sugar in 15 minutes, with notification of the MD or transfer to the ER if the result remained below 60 mg/dl. Resident 43 stated during interview that her blood sugar levels had been low lately. Review of the MAR for March 2026 showed three occasions when Resident 43’s blood sugar was documented below 70 mg/dl: 68 mg/dl, 67 mg/dl, and 69 mg/dl. For each of these episodes, there was no documentation of a repeat blood sugar check after the initial low reading. The DON and ADON reviewed the record and stated they were unable to find documented evidence anywhere in the clinical record that the blood sugar had been rechecked on those dates, and the DON stated the follow-up blood sugar levels should have been documented as a progress note.
Low Air Loss Mattress Set Incorrectly
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one sampled resident with pressure ulcers. Resident 6 was admitted with diagnoses including congestive heart failure, type 2 diabetes mellitus, age related osteoporosis, muscle wasting and atrophy, and major depressive disorder. The resident was observed lying in bed on a low air loss mattress, and the mattress was programmed to 350 lbs. During a concurrent observation and interview, LVN 1 stated low air loss mattresses are intended to prevent pressure ulcers from forming and to keep existing pressure ulcers from worsening, and that they are supposed to be set according to physician orders. After reviewing the physician's order, LVN 1 stated the mattress was incorrectly set and should have been set to 70-80 lbs, but was instead set to 350 lbs. The DON stated low air loss mattresses are supposed to be programmed for the correct weight as indicated in the physician's order and that if they are not, it defeats the purpose of trying to reduce pressure and prevent pressure ulcers from developing or worsening.
Failure to Follow Suprapubic Catheter and Drainage Bag Orders
Penalty
Summary
Resident 4, who was readmitted with diagnoses including end stage renal disease, dependence on renal dialysis, obstructive uropathy, and reflux uropathy, had a suprapubic catheter in place with physician orders dated January 4, 2026. The orders directed staff to change the catheter bag every Sunday and as needed if leakage, blockage, or soiling occurred, and to irrigate the suprapubic catheter as needed with 60 cc normal saline to prevent blockage. During an observation in the resident’s room, the urinary collection bag was found resting on the mattress between the resident’s legs, containing cloudy, concentrated urine with significant sediment in the tubing and a foul odor, and it was not labeled with a date or positioned to allow proper drainage. During the same observation, the Infection Preventionist acknowledged the bag was lying on the mattress between the resident’s legs, showed signs of long-term use, and was not properly positioned to allow adequate drainage. The IP was unable to state when the bag had last been changed and was unable to state how often or when the suprapubic catheter had last been flushed. A review of the Treatment Administration Record for January through April 2026 showed no documentation that the drainage bag had been changed since the order was received and no documentation that the suprapubic catheter had been flushed since the order was received. During interview and record review with the Administrator and ADON, the facility confirmed there was no documentation that the urinary collection bag had been changed or that the suprapubic catheter had been flushed as ordered. The Administrator stated staff were most likely not aware of the weekly drainage bag change order. The facility’s policy on close drainage systems for urinary drainage bags was also reviewed, and the Administrator and ADON acknowledged that the policy was not followed.
Inaccurate Dialysis Access Assessment Documentation
Penalty
Summary
Nursing staff failed to demonstrate competency in monitoring a dialysis access site for a resident with end stage renal disease and dependence on renal dialysis. The resident was admitted with diagnoses including end stage renal disease, dependence on renal dialysis, and legal blindness, and was receiving hemodialysis three times a week. During observation, the resident stated his dialysis access was a central venous catheter on the right chest, and a central venous catheter with a dressing was observed at the chest insertion site. The resident's physician's orders included monitoring a shunt on the right upper chest for bruit every shift and notifying the MD if none was felt, and monitoring a shunt on the right upper chest for thrill every shift and notifying the MD if none was felt. Despite the resident having a central venous catheter and not a fistula or shunt, the MAR showed these tasks were documented as completed on 70 different shifts by six licensed nurses for bruit and on 70 different shifts by seven licensed nurses for thrill. The DON stated bruit and thrill can only be checked on a shunt or fistula and not on a central venous catheter, and that the order was inappropriate because the resident only had a central venous catheter. The DON also stated the order was never clarified and no licensed nurse questioned it. The ADON stated staff entered the order to check bruit and thrill on a central venous catheter but only check those findings on a fistula or shunt, and acknowledged that numerous nurses documented successful checks despite the resident having only a central venous catheter. An RNS and an LVN also acknowledged documenting bruit and thrill checks, with the LVN stating she assessed the arm where a shunt or fistula would usually be located and thought she heard and felt bruit and thrill even though the resident did not have a shunt or fistula.
Metformin Given Without Food as Ordered
Penalty
Summary
The facility failed to ensure Metformin was administered as prescribed for one sampled resident with Type 2 Diabetes Mellitus and a gastrostomy tube. During a medication administration observation, the resident’s blood sugar was 83, and an LVN crushed one 500 mg Metformin tablet and administered it via the G-tube with a water flush, then left the room without providing food. The resident’s physician order stated Metformin 500 mg via G-tube every morning and at bedtime, with instruction to take with food or by mouth, and the resident also had an order for a controlled carbohydrate diet. During interview and record review, the LVN read the pharmacy label instructions stating to take the medication with a meal and acknowledged the medication had been given without food and not in accordance with the physician’s order. The ADON later confirmed the physician’s orders were not followed and stated Metformin should have been administered with food. The facility’s policy also stated to follow administration instructions and offer adequate fluid with oral medications, and the Administrator acknowledged the facility’s policy and procedure was not followed.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for two sampled residents. Resident 5’s admission record showed diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side. During an observation, Resident 5 was lying in bed awake, and the call light was found on the floor on the resident’s right side of the bed and unreachable. An LVN acknowledged the call light had fallen to the floor after medication was given and stated it must be within the resident’s reach at all times. Resident 5 stated she could not access the call light and would likely have to yell for help if she needed assistance. Resident 9’s admission record showed diagnoses including paraplegia, acute and chronic respiratory failure, contracture of muscles, and dementia. During an observation, Resident 9 was lying in bed asleep, facing the wall and covered with blankets, while the call light was wrapped around the feeding pump on a pole away from the resident’s reach. A CNA and the MDSC both acknowledged the call light was not within reach, and the MDSC stated it should have been clipped on the bed linens within reach. The Administrator acknowledged the facility policy was not followed when Resident 9’s call light was wrapped around the feeding pump and out of reach.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present onsite for at least eight hours a day, seven days a week, as required by regulation. Specifically, there was no RN coverage on three separate days within the review period. On April 10, 2025, it was observed that no RN was on duty, and the Administrator confirmed that the Director of Nursing (DON), who is the only full-time RN, was absent due to illness. The only other RN on staff was part-time and only scheduled for two days per week, leaving gaps in RN coverage. A review of timecards and interviews with the Administrator confirmed that there was no RN present on March 19, March 27, and April 10, 2025. The facility's own policy requires an RN to be present for eight hours each day to meet resident needs and regulatory requirements. The census at the time was 58 residents, and the absence of RN coverage on these days constituted a failure to comply with both facility policy and regulatory standards.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by several deficiencies. Firstly, the facility did not conduct an annual review of its infection control program's policies and procedures, which were last revised in June 2021. This oversight was confirmed during an interview with the Administrator, who acknowledged that the policies should be reviewed and updated at least annually. The lack of an updated review had the potential to leave the facility out-of-date with current best practices and overlook potential gaps in their procedures. Additionally, the facility's laundry and housekeeping staff did not adhere to the manufacturer's guidelines for the disinfectants used. During an observation, a laundry staff member described using a multi-use cleaner instead of the recommended disinfectant for cleaning laundry barrels, and did not allow the disinfectant to remain wet for the required 10 minutes on laundry baskets. Similarly, housekeeping staff did not follow the guidelines for disinfecting resident rooms, failing to keep surfaces wet for the necessary time and using a multi-use cleaner on floors instead of the disinfectant. These actions were contrary to the instructions provided by the Infection Preventionist and had the potential to cause the development and transmission of communicable diseases and infections. Furthermore, housekeeping staff did not follow Enhanced Standard Precautions (ESP) when cleaning designated rooms. During an observation, a housekeeping staff member was found cleaning an ESP room without wearing a gown, which is a required form of Personal Protective Equipment (PPE) for such tasks. The staff member admitted to forgetting to wear the gown, and the Housekeeping Supervisor confirmed the oversight. This failure had the potential to cause the transmission of multidrug-resistant organisms (MDROs) to the staff member's clothing and subsequently to other residents.
Inaccurate RAI-MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) for four residents, leading to potential unmet care needs and inaccurate clinical records. Resident 25's assessment incorrectly indicated minimal hearing loss and no hearing aid, despite the resident's communication difficulties and the presence of hearing aids stored in the Social Services Director's office. The MDS nurse acknowledged the error, noting the resident's hearing had worsened and the assessment needed correction. Resident 27's assessment inaccurately reflected the resident's Pre-Admission Screening and Resident Review (PASRR) status, marking them as not requiring a Level 2 PASRR, despite documentation indicating a Level 2 evaluation had been conducted. The MDS nurse admitted to the mistake, which contradicted the PASRR Determination Report that should have been incorporated into the resident's care plan. Resident 32's assessment erroneously recorded insulin administration, which was not supported by the Medication Administration Record. The MDS nurse confirmed the error upon review. Similarly, Resident 56's assessment incorrectly noted the presence of an indwelling urinary catheter, which had been removed months prior. The MDS nurse acknowledged the mistake, and it was revealed that the facility lacked a specific policy and procedure for completing RAI-MDS assessments, relying instead on the RAI-MDS assessment manual.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a survey. Firstly, the walk-in refrigerator and freezer temperatures were not being monitored daily, as there was no thermometer present, and the logs for temperature checks were missing. This lack of monitoring could lead to food being stored at unsafe temperatures, increasing the risk of bacterial growth. The Dietary Supervisor acknowledged the absence of these critical items and the importance of maintaining temperature records. Additionally, a kitchen staff member was observed working without a hair net, which is a violation of the Federal FDA 2017 Food Code that requires food employees to wear hair restraints to prevent contamination. The Dietary Supervisor admitted to forgetting to wear a hair net. Furthermore, the walk-in refrigerator had shelves with black residue, indicating a lack of cleanliness. The Dietary Supervisor confirmed the need for cleaning. These deficiencies posed a potential risk for foodborne illness among the 49 residents who consumed food from the kitchen.
Cockroach Infestation in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchen, as evidenced by the observation of a cockroach on the wall behind the steam table. This incident was noted during an observation and interview with the Dietary Supervisor, who acknowledged that there should not be any bugs or cockroaches in the kitchen. The presence of the cockroach was a direct violation of the State Operations Manual S483.90(i)(4), which mandates an effective pest control program to ensure the facility is free of pests and rodents. The Dietary Supervisor admitted that the facility was out of compliance due to this issue. Further interviews and record reviews revealed that the facility's policy and procedure for pest control required staff to report any pest sightings to the food services manager, who would then take appropriate action. However, the Service Inspection Report from December 12, 2024, only indicated pest control maintenance without any detailed comments or explanations of actions taken. The Infection Preventionist expressed concern about the potential for cockroaches to spread disease, highlighting the infection control risks associated with the presence of pests in the kitchen.
Failure to Discuss and Document Advance Directives
Penalty
Summary
The facility failed to provide evidence that staff discussed with Resident 32 whether the resident had an existing advance directive and did not educate the resident on their rights to establish a new advance directive if desired. During an interview and record review, the Director of Nursing (DON) was unable to provide evidence of an advance directive for Resident 32, only presenting a Physician Orders for Life-Sustaining Treatment (POLST) form signed by the resident in 2020. The POLST form had a section regarding advance directives that was left unanswered, indicating a lack of documentation on whether Resident 32 had an advance directive in place. Further interviews with the Registered Nurse Supervisor (RNS 1) and the Social Services Director (SSD) confirmed that the section on the POLST regarding advance directives was incomplete and that there was no Advance Directive Acknowledgement form in Resident 32's clinical record. The facility's policy required that residents be provided with information about their rights to accept or refuse medical treatment and to formulate an advance directive, but there was no evidence that this was done for Resident 32. The responsibility for completing these forms was attributed to the social worker, but the necessary documentation was not found in the resident's records.
Failure to Provide Beneficiary Liability Notifications
Penalty
Summary
The facility failed to provide two residents with the necessary beneficiary liability protection notifications, which are crucial for informing residents about their financial responsibilities and rights to appeal. Resident 17 was not given an estimated cost on the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), which is meant to inform residents about potential non-coverage and the option to continue services with the resident accepting financial liability. The Business Office Manager (BOM) acknowledged that the SNF ABN form for Resident 17 incorrectly indicated 'NA' for the estimated cost, instead of the actual daily room rate of $325. Similarly, Resident 28 was not provided with an estimated cost on their SNF ABN, and the Notice of Medicare Non-Coverage (NOMNC) was not given at least two days before the end of their Medicare-covered Part A stay. The BOM confirmed that the SNF ABN form for Resident 28 also showed 'NA' for the estimated cost, and the NOMNC form was not provided in a timely manner. The BOM admitted that the NOMNC should have been given three days in advance, but it was not, and there was a different business office manager at the time. The facility's policy and procedure titled 'Medicare Termination Notification' requires that residents be notified no later than two days prior to the last day of coverage. This policy was not followed for Resident 28, as the NOMNC was not provided within the required timeframe. The failure to provide these notifications had the potential to leave Residents 17 and 28 uninformed about their financial liabilities and their rights to appeal.
Failure to Provide Written Notification of Resident Transfer
Penalty
Summary
The facility failed to provide written notification to a resident's representative regarding the transfer of the resident to a hospital. This deficiency was identified during a review of the resident's records and interviews with facility staff and the resident's representative. The resident, who has a diagnosis of schizophrenia and metabolic encephalopathy, was transferred to the hospital due to vomiting dark liquid. The resident's representative was informed of the transfer via a phone call, but no written notice was provided as required by regulations. During the investigation, it was confirmed that the facility's notice of proposed transfer/discharge was communicated verbally to the resident's representative, but not in writing. The State Operations Manual S483.15(c)(3) mandates that such notifications be provided in writing and in a language and manner understandable to the resident and their representative. The Social Services Director acknowledged that the written notice was not provided, which is a violation of the regulatory requirements.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as Resident 51, who was at risk for skin breakdown due to existing pressure ulcers and deep tissue injuries. The resident's care plan and physician's orders specified the use of a low air loss mattress set to a specific pressure range and the application of heel protectors while in bed. However, during an observation, it was noted that the resident's mattress was set to an incorrect pressure of 80 mmHg, significantly lower than the prescribed range of 155-165 mmHg. Additionally, the resident was not wearing heel protectors, contrary to the care plan requirements. The deficiency was further compounded by inaccurate documentation in the resident's Electronic Medical Record (EHR). A nursing weekly summary inaccurately reported that the resident's skin was intact, failing to acknowledge the existing deep tissue injury to the heel. This incorrect documentation was confirmed by the Director of Nursing (DON), who acknowledged that the nurse responsible for the assessment did not accurately identify the resident's skin condition. The facility's policy and procedure for resident assessment and care planning emphasized the importance of comprehensive, person-centered care plans and accurate weekly assessments to detect changes in condition and identify new or altered resident needs. However, the failure to adhere to these protocols resulted in the potential for worsening pressure ulcers and delayed identification and treatment of new pressure ulcers for Resident 51.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure that a fall mat was placed next to the bed of a resident, as specified in the resident's care plan. This deficiency was identified during an observation where the resident, who was nonverbal and had a history of falls, was found without a fall mat next to her bed. The resident's care plan, which was designed to prevent falls and minimize injury, clearly indicated the need for a fall mat due to the resident's high risk for falls related to conditions such as dementia, legal blindness, and balance problems. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed a lack of awareness and understanding of why the fall mat was not in place. The facility's policy on fall prevention emphasized the importance of assessing residents for fall risks and implementing appropriate measures, yet this was not adhered to in the case of the resident. The absence of the fall mat was acknowledged by the Director of Nursing, who confirmed that it was supposed to be part of the resident's fall prevention strategy.
Inadequate Room Size for Residents
Penalty
Summary
The facility failed to ensure that five rooms, each occupied by four residents, met the minimum required square footage per resident. The rooms in question were Rooms 102, 105, 106, 107, and 112, which were observed to have less than the required 80 square feet per resident. Measurements taken by the Maintenance Supervisor and verified by the surveyor showed that the rooms ranged from approximately 71.35 to 75.4 square feet per resident after accounting for the space occupied by moveable wardrobe cabinets. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the rooms did not meet the required space standards. The deficiency was identified through observations, interviews, and record reviews conducted by the surveyors. During the survey, it was noted that the limited space in these rooms posed potential risks, including increased chances of accidents and injuries due to restricted space for wheelchairs and Hoyer lifts, limited room for resident care activities, and potential delays in emergency evacuations. The Administrator agreed that the inadequate room sizes could lead to negative outcomes such as falls and accidents. Additionally, the facility lacked a policy and procedure regarding the minimum required square footage for resident rooms. A review of the facility's document indicated that out of the 20 residents housed in the affected rooms, 10 required the use of a Hoyer lift, nine used wheelchairs, and seven used Geri chairs. This further highlighted the inadequacy of the room sizes in accommodating the needs of residents with mobility aids.
Failure to Post Staffing Information in Resident-Accessible Area
Penalty
Summary
The facility failed to ensure that daily staffing information was posted in an area accessible to residents, affecting all 55 residents. On December 17, 2024, it was observed that the staffing information, including Direct Care Service Hours Per Patient Day (DHPPD), was posted near the facility's main entrance. However, this area was not accessible to residents as it required passing through a locked door or going behind the nurses' station, both of which were restricted to residents. During interviews, the Director of Staff Development (DSD) confirmed that he was responsible for posting the DHPPD information and acknowledged that it was only posted at the front entrance, which residents could not access. The Director of Nursing (DON) also stated that the DHPPD information should be posted in an area accessible to both residents and visitors. The facility's policy and procedure indicated that the information should be posted on a bulletin board in a conspicuous place visible to residents and visitors, which was not adhered to in this instance.
Inaccessible Survey Results for Residents
Penalty
Summary
The facility failed to post the results of its most recent survey in a location that was readily accessible to residents. The survey results were placed in a binder on a front lobby wall, but access to this area was restricted due to a locked door between the residents' living area and the lobby. This door was kept locked to prevent residents from leaving the building unmonitored, as confirmed by a Registered Nurse Supervisor and a Licensed Vocational Nurse during an observation and interview. The facility's Administrator acknowledged that the residents did not have free access to the survey results binder, which was contrary to the facility's policy on residents' rights. The policy, dated January 2019, stated that residents have the right to examine the results of the most recent survey conducted by Federal or State surveyors. This deficiency was identified during an observation, interview, and record review, affecting all 55 residents in the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 695 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Shandin Hills Behavior Therapy Center | 1.2 mi | ★★★★★ | 7 | 0 |
| Hillcrest Nursing Home | 1.2 mi | ★★★★★ | 6 | 0 |
| Haven Post Acute | 2.5 mi | ★★★★★ | 1 | 0 |
| Waterman Canyon Post Acute | 2.6 mi | ★★★★★ | 2 | 0 |
| Valley Healthcare Center | 2.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.