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 Arrowhead Springs Healthcare during CMS and state inspections, most recent first.
A recycling container outside the facility was found overflowing with open cardboard boxes and its lid left open. Staff and administration confirmed that the container should be closed and boxes should be broken down to allow proper closure, in accordance with facility policy and FDA Food Code requirements.
A resident with multiple health conditions was found lying on a mattress that was peeled, discolored, and in disrepair. The facility's policy requires contacting the vendor for repair or replacement of such equipment, but the mattress remained in use at the time of the survey.
Two residents did not have comprehensive, person-centered care plans developed to address their specific medical needs. One resident lacked a care plan for podiatry services despite ongoing issues with long nails and a physician's order for nail care, while another resident did not have a care plan for IV antibiotic therapy for osteomyelitis. The ADON confirmed that required care plans were not initiated as per facility policy.
A resident with mobility and medical issues was found with long, thickened, yellow toenails and untrimmed fingernails after repeatedly requesting assistance with nail care. Despite a physician's order for nail care and a podiatry appointment, staff did not provide routine nail trimming or document follow-up, contrary to facility policy requiring nursing staff to manage such care as part of regular hygiene and grooming.
A resident with multiple medical conditions and a high fall risk was not provided with physician-ordered bilateral side rails for over a month, despite a completed safety assessment and informed consent. The resident had requested the side rails and signed the necessary documentation, but the facility did not install them as required by policy, leaving the resident without the prescribed safety intervention.
A resident with multiple cardiac and respiratory conditions was found receiving continuous oxygen therapy with the oxygen tubing lying on the floor under the bed. An LVN acknowledged the tubing was contaminated, and the Infection Preventionist confirmed this was not in accordance with facility policy, which requires oxygen tubing to be kept off the floor to prevent contamination.
A resident with a history of falls and high fall risk was not provided with adequate preventive measures, leading to a fall and head injury. Despite care plan recommendations for floor mats and a falling star indicator, these were absent, resulting in the resident being sent to the hospital for treatment. Staff interviews revealed a lack of awareness and implementation of necessary fall prevention measures.
Several residents experienced significant delays in response to call lights and inadequate care, particularly during the night shift. One resident with epilepsy and diabetes waited an hour for assistance, while another was left in a soiled diaper for over an hour. A third resident with low blood sugar waited three hours for help, and a fourth resident with amputations faced long wait times for assistance. Staff interviews revealed a lack of awareness and communication about these issues, despite facility policies emphasizing timely and respectful care.
A resident with quadriplegia and a history of falls sustained a laceration after falling off the bed during care by a CNA who did not seek the required assistance. The resident's care plan indicated the need for one to two persons for assistance, which was not followed, leading to the incident.
The facility failed to implement their infection prevention and control program when a resident on enhanced barrier precautions (EBP) did not have identifiable EBP signage outside their room, as required by the facility's policy and CDC guidance. Staff interviews and observations confirmed the absence of proper signage and PPE, increasing the risk of MDRO transmission.
Improper Disposal and Overflowing Recycling Container
Penalty
Summary
A deficiency was identified when one of the outside recycling containers was observed to be overflowing with open cardboard boxes and its lid was not closed. This observation was made in the presence of the Registered Dietician, who confirmed that the recycling container should be closed and not overflowing. The Administrator also acknowledged that staff are expected to break down and flatten boxes so that the recycling receptacle can be properly closed, noting the potential to attract pests. Review of the facility's undated policy and procedure on garbage and trash indicated that adequate, clean, vermin-proof areas must be provided for storage and that trash cans must be inspected daily. Additionally, the FDA Food Code 2022 requires outside refuse and recycling receptacles to have tight-fitting lids, doors, or covers.
Damaged Mattress Not Replaced for Resident
Penalty
Summary
A deficiency was identified when a resident's mattress was observed to be peeled, discolored, and in disrepair. During an observation in the resident's room, the mattress was found to be damaged at the foot of the bed while the resident was lying in it. The facility's policy requires that equipment in need of repair or replacement be addressed by contacting the vendor, but the mattress remained in use in its deteriorated condition at the time of the survey. The resident involved had a medical history including morbid obesity, type 2 diabetes mellitus with circulatory complications, and anxiety disorder. The facility administrator acknowledged the condition of the mattress during the survey and reviewed the facility's policy, which outlines procedures for repair or replacement of equipment. However, the mattress had not been replaced or repaired prior to the surveyor's observation.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with specific medical needs. One resident, admitted with multiple diagnoses including difficulty walking, chronic heart failure, and a history of TIA, did not have a care plan addressing ongoing podiatry needs for long fingernails and toenails since admission. Despite a physician's order for a nail care appointment and the resident's repeated requests for assistance with nail care, there was no documented care plan for podiatry services. The Assistant Director of Nurses (ADON) confirmed that a care plan should have been initiated upon admission but was not. Another resident, admitted with acute osteomyelitis of the left ankle and foot, end stage renal disease, and immunodeficiency, did not have a care plan developed for intravenous (IV) antibiotic therapy with Ceftazidime. The resident had a physician's order for IV antibiotics to treat the bone infection, but no care plan was initiated when the therapy began. The ADON acknowledged that staff did not follow the facility's policy requiring the development of a comprehensive care plan for each resident, including baseline care plans within 48 hours of admission.
Failure to Provide Routine Nail and Hygiene Care
Penalty
Summary
The facility failed to provide proper hygiene and grooming care for a resident who was unable to perform these activities independently. The resident, who had a history of difficulty walking, chronic heart failure, and a previous transient ischemic attack, was observed to have long, thickened, yellow toenails curling over the tips of both feet, as well as long, untrimmed fingernails. The resident reported having requested nail trimming from staff multiple times without receiving assistance and stated he had not been seen by a podiatrist since admission. Observations by staff confirmed the condition of the resident's nails and dry, cracked skin on the feet. Review of the resident's records showed a physician's order for a nail care appointment and documentation of a podiatry visit, but there was no evidence of follow-up or routine nail care by nursing staff as required by facility policy. The Assistant Director of Nurses acknowledged that the resident was not diabetic and that nail care should have been performed by CNAs or licensed nursing staff as part of routine grooming. The facility's policy indicated that routine foot care, including nail trimming, should be managed by licensed nurses, but there was no documentation explaining the delay or lack of care. Staff failed to identify and address the resident's hygiene needs during routine assessments, resulting in the deficiency.
Failure to Implement Physician-Ordered Bed Rails for High-Risk Resident
Penalty
Summary
The facility failed to implement physician-ordered bilateral side rails for a resident who had been assessed as high risk for falls and had provided informed consent for their use. Despite a completed safety assessment, physician order, and signed consent form, the side rails were not installed for 37 days. The resident, who had a history of kidney transplant, congestive heart failure, pancytopenia, and an above-the-knee amputation, expressed feeling unsafe and reported that the trapeze alone was insufficient for his needs. The resident had specifically requested the side rails and completed all necessary documentation, but the intervention was not carried out. Interviews and record reviews confirmed that the facility's policy required assessment, informed consent, and proper installation of side rails when indicated. The Assistant Director of Nursing acknowledged that the order and assessment were completed, but the side rails were not implemented as required by policy. This lapse was observed during a site visit, where the resident was found lying close to the edge of the bed without the ordered side rails in place, despite being at high risk for falls and having mobility limitations.
Oxygen Tubing Found on Floor During Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident's oxygen tubing was observed lying on the floor under the bed while the resident was in bed with the oxygen concentrator in use. The tubing was connected to a humidifier and nasal cannula, and the resident was receiving continuous oxygen therapy as ordered by the physician. The Licensed Vocational Nurse present at the time acknowledged that the tubing was on the floor and confirmed it should not be there due to contamination concerns. Review of the facility's policy and procedure for oxygen use indicated that tubing should be kept off the floor to promote resident safety and prevent bacterial contamination. The Infection Preventionist Nurse confirmed that staff did not follow this policy, as the tubing was found touching the floor. The resident involved had a medical history including acute chronic diastolic heart failure, paroxysmal atrial fibrillation, and generalized muscle weakness, and was admitted with an order for continuous oxygen therapy.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and preventive measures for a resident identified as high risk for falls, resulting in an avoidable accident. The resident, who had a history of falling and was admitted with conditions including syncope, hypertension, and urinary tract infection, fell out of bed and sustained an open laceration to the right side of the head. This incident required the resident to be sent to an acute hospital for further evaluation and treatment, where they received staples for the injury. Upon review, it was found that the resident's care plan included interventions such as keeping the bed in the lowest position and using bilateral floor mats to mitigate fall risks. However, during an observation, it was noted that no floor mats were present at the resident's bedside, contrary to the care plan recommendations. Additionally, the resident's room lacked a falling star indicator, which is used to alert staff of a resident's fall risk status. Interviews with facility staff, including CNAs and an LVN, revealed a lack of awareness and implementation of the necessary fall prevention measures. The staff acknowledged the absence of floor mats and the falling star indicator, which were supposed to be in place following the resident's room change. The facility's policy on fall management emphasizes the importance of individualized care plans and interventions to prevent falls, which were not adequately followed in this case.
Delayed Response to Call Lights and Inadequate Care
Penalty
Summary
The facility failed to adhere to its Activities of Daily Living (ADLs) policy and procedure for four residents, leading to significant delays in response times to call lights and inadequate care. Resident 1, who has epilepsy, diabetes type II, and a history of cerebral infarction, reported that it took an hour for staff to respond to their call light, and during the night shift, staff did not respond at all. Resident 2, with a fractured femur and diabetes, was left in a soiled diaper for over an hour during the night shift, which was corroborated by their doctor. Resident 3, who has diabetes, rhabdomyolysis, and fibromyalgia, experienced a three-hour wait for assistance after using the call light due to low blood sugar. Despite hearing staff conversing in the hallway, they did not receive timely help, which was critical given their medical condition. Resident 4, with bilateral above-knee amputations and diabetes, also faced long wait times for assistance, particularly during the night shift, and had been raising this issue in council meetings for two months without resolution. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Director of Staff Development (DSD), revealed a lack of awareness and communication regarding these issues. The facility's policies on ADLs, call lights, and resident rights emphasize timely and respectful care, yet these were not followed, resulting in potential risks to the residents' health and safety. The facility's administration claimed to be unaware of these issues, despite having systems in place to monitor call light response times.
Resident Falls Due to Inadequate Assistance During Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice for a resident who fell off the bed during care by a Certified Nursing Assistant (CNA). The resident, who had a history of falling and required assistance due to conditions such as quadriplegia and cerebral palsy, sustained a laceration on her right eyebrow as a result of the fall. The incident occurred when CNA 2 was providing care without the necessary assistance, despite the resident's care plan indicating that one to two persons were needed for assistance during activities of daily living. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed that the resident typically required two persons for turning, changing, and transferring during care. The facility's policy on managing falls and fall risks emphasized the need for staff to identify interventions to prevent falls based on evaluations and current data. However, the failure to adhere to these guidelines and the resident's care plan led to the incident, highlighting a deficiency in the facility's care practices.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement their infection prevention and control program when a resident on enhanced barrier precautions (EBP) did not have identifiable EBP signage outside their room, as required by the facility's policy and CDC guidance. This failure was observed during a survey, where it was noted that there was no signage or personal protective equipment (PPE) available outside the resident's room. The resident had been placed on EBP due to end-stage renal disease and dependence on hemodialysis, which increased their risk of multidrug-resistant organisms (MDROs). The absence of proper signage and PPE availability had the potential to prevent staff from recognizing the need for enhanced precautions, thereby increasing the risk of MDRO transmission. During interviews, staff members, including a CNA and the Director of Staff Development (DSD), confirmed that the facility's protocol required an EBP sign and an orange sticker next to the resident's name. However, the CNA was unaware of the significance of the orange sticker and mistakenly believed it indicated hepatitis. The Infection Preventionist (IP) acknowledged that the EBP sign was missing and suggested it might have been removed when the resident temporarily left the facility and was not replaced upon their return. A review of the facility's policy and CDC guidance confirmed that clear signage and immediate availability of PPE outside the resident's room were mandatory. The IP admitted that the facility did not follow its own policy and procedure, which was corroborated by the absence of the required EBP sign and PPE. This oversight was a clear deviation from the established infection control measures designed to prevent the spread of communicable diseases and conditions within the facility.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Medical Center Convalescent Hospital | 0.2 mi | ★★★★★ | 13 | 0 |
| Valley Healthcare Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Waterman Canyon Post Acute | 0.5 mi | ★★★★★ | 2 | 0 |
| Haven Post Acute | 1.6 mi | ★★★★★ | 1 | 0 |
| Del Rosa Villa | 1.8 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.