Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Failure to Provide Written Notice of Non-Covered Service Charges: The facility did not give written notice of the daily out-of-pocket cost for continued stay on SNF ABN forms for three residents. The Admin said the cost was only explained verbally and posted in the building, and the AD confirmed residents were not given written notice once Medicare coverage ended; the facility also had no written policy for beneficiary notification.
PASARR assessments were not updated for two residents whose admission records included psychiatric diagnoses. One resident’s PTSD was not identified on the PASARR used for admission, and another resident’s paranoid schizophrenia was also omitted. The MDS nurse and MDS 2 acknowledged the assessments were inaccurate, and the DON stated the PASRR policy was not followed.
Failure to Deliver Ordered Enteral Feeding Volumes: Three residents who depended on tube feeding did not receive the full ordered formula volumes. One resident with CVA-related conditions, one with Parkinson’s disease, cerebral palsy, and dysphagia, and one with hemiplegia, dysphagia, and aphasia each had continuous G-tube feeding orders, but observations and staff interviews showed the pump was stopped or disconnected before the prescribed amounts were delivered. The RD confirmed that each resident received less than the ordered volume, and staff stated the full dose was not tracked or completed as ordered.
Unassessed Self-Administration of Medications: A resident with COPD and a right shoulder fracture had three medications left unattended at the bedside and stated she used them herself. The resident had a BIMS score of 12, but there was no self-administration assessment, IDT review, physician authorization, or care plan supporting self-administration, and the DON confirmed the facility’s policy was not followed.
A resident’s annual MDS was not accurately coded in Section I for active diagnoses because Anxiety Disorder was left blank even though the resident’s record showed that diagnosis. The DON reviewed the assessment, verified the coding error, and stated the resident did have Anxiety Disorder; the facility’s RAI/MDS 3.0 policy was also reviewed, and the DON stated it was not followed.
PASARR screening was not completed for a resident who stayed beyond 30 days after admission with DVT, pneumonia, and cerebral infarction. The MDS nurse stated the Level I result of Exempted Hospital Discharge meant the screening should have been completed, but it was not done even though the resident remained in the facility for 49 days. The DON confirmed the PASRR policy was not followed and that the screening should have been completed.
Medication Administration Errors Exceeded Allowed Rate: Surveyors found 3 medication errors in 36 observed opportunities, resulting in an 8.3% error rate. A resident missed an ordered dose of Omeprazole because it was unavailable, and another resident received the wrong dose of Vitamin D3 and had a scheduled Vitamin B12 dose delayed beyond the required time. The DON confirmed the medication administration policies were not followed.
Unsecured Medications Left at Resident Bedside: A resident with COPD, GERD, and a right shoulder fracture had an MDS showing moderate cognitive impairment, yet an inhaler, Nystatin cream, and Diclofenac topical gel were found unattended and readily accessible on the bedside table. The resident confirmed she was still using the medications, an LVN acknowledged they belonged to her and that leaving them there was unsafe, and the DON confirmed one Nystatin order had been discontinued but was still left in the room. The facility policy required medications to be stored safely and securely, and the DON stated staff did not follow it.
Failure to disinfect a reusable medication tray between residents. An LVN gave meds to one resident, returned used cups and a spoon to the tray, and then used the same uncleaned tray to prepare meds for two additional residents. The LVN acknowledged the tray should have been cleaned and disinfected between residents, and the DON confirmed the facility policy required disinfection of noncritical items between each resident use.
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.
Failure to Provide Written Notice of Non-Covered Service Charges
Penalty
Summary
The facility failed to inform residents, in writing, of services available and the charges for those services, including charges for items and services not covered by Medicare or Medicaid, for three sampled residents. Resident 122's Skill Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form, dated December 2, 2025, was missing the required cost-per-day amount for continued stay in the facility. Resident 120's SNF ABN form, dated February 12, 2026, was also missing the required cost-per-day amount, and Resident 121's SNF ABN form, dated January 19, 2026, was missing the same required cost-per-day amount. During interviews on June 3, 2026, the Administrator stated the facility does not include the cost of stay on the SNF ABN paperwork and that the Admissions Concierge verbally informs residents of the out-of-pocket cost. The Admissions Concierge stated the cost is posted in four locations throughout the facility and residents are informed verbally. The Admissions Director confirmed residents were not provided written notice of their daily cost to remain in the facility once Medicare coverage ends, and later stated the facility does not have a written policy addressing beneficiary notification and just follows the regulation.
PASARR Assessments Did Not Reflect Psychiatric Diagnoses for Two Residents
Penalty
Summary
The facility failed to update PASARR assessments for two sampled residents when their psychiatric diagnoses were not included in the screening used for admission. Resident 17 was admitted with diagnoses including cervical region spinal stenosis, PTSD, and sleep apnea, but the PASARR assessment dated April 29, 2026 indicated “NO” to diagnosed serious mental illness and did not identify PTSD. During interview and record review, the MDS nurse acknowledged the PASARR did not accurately reflect the resident’s PTSD and stated a revision should have been completed, but it was not done. Resident 76 was admitted with diagnoses including hemiplegia, hemiparesis, cerebral infarction, and paranoid schizophrenia, but the PASARR assessment dated March 29, 2019 indicated “NO” to diagnosed mental illness and did not identify schizophrenia. During interview and record review, the MDS nurse and MDS 2 acknowledged the PASARR did not accurately indicate paranoid schizophrenia and stated a revision should have been completed, but it was not done. The DON reviewed the facility’s PASRR policy and stated it was not followed, and that PASARR screening reassessment should have been done for both residents.
Failure to Deliver Ordered Enteral Feeding Volumes
Penalty
Summary
The facility failed to provide the ordered volume of enteral feeding to three residents who were dependent on tube feeding for nutrition and hydration. Resident 4 had diagnoses including sequelae of cerebral infarction, pneumonitis due to inhalation of food and vomit, and diabetes mellitus, and had an order for continuous enteral feeding via G-tube at 75 mL/hr for 20 hours to provide 1500 mL. During observation, the feeding bottle was found infusing, but the LVN stated she did not know how much formula had been infused and that the prior shift had not told her how much had already been delivered. The RD confirmed that Resident 4 should have received 300 mL during the observed period but only 100 mL was given. Resident 13 had diagnoses including Parkinson’s disease, cerebral palsy, and dysphagia, and had an order for continuous enteral feeding via G-tube at 70 mL/hr for 20 hours to provide 1400 mL. When observed, the formula bottle remained connected to the pump with 700 mL still in the bottle, and the pump was off. The LVN who hung the formula stated the resident should receive 1400 mL but could not say the resident got exactly that amount. The RD later confirmed that Resident 13 received only 800 mL of the prescribed 1400 mL and did not receive the remaining 600 mL. Resident 24 had diagnoses including hemiplegia, hemiparesis following cerebral infarction, dysphagia following cerebral infarction, and aphasia following cerebral infarction, and had an order for continuous enteral feeding via G-tube at 90 mL/hr for 20 hours to provide 1800 mL. During observation, the resident was unresponsive and the formula bottle was still hung with formula remaining. Later observation showed the pump was off and disconnected, and the LVN confirmed the resident did not receive the entire ordered amount from the bottle hung the prior day and that a second bottle should have been hung to provide the full ordered volume. The RD confirmed the resident received only 1200 mL of the ordered 1800 mL.
Unassessed Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was assessed and authorized to self-administer medications when three medications were found at Resident 47’s bedside within reach and readily accessible without a completed self-administration assessment, interdisciplinary team review, or physician authorization. Resident 47 was admitted with diagnoses of COPD and displacement fractures of the right shoulder glenoid cavity, and during observation on June 1, 2026, the resident was lying in bed with the head of the bed elevated and wearing a sling on the right arm. Three medications were observed unattended on the bedside table: Diclofenac gel, Nystatin cream, and Fluticasone Propionate/Salmeterol inhaler. Resident 47 stated that she uses the medications herself. During a concurrent observation and interview, LVN 5 stated the inhaler had a handwritten open date of May 16, 2026, with 52 doses remaining out of 60 doses, and confirmed the medications belonged to Resident 47 and that it was unsafe to leave them unattended on the bedside table. Review of the resident’s MDS dated May 19, 2026, showed a BIMS score of 12. The DON later reviewed the electronic record and stated Resident 47 did not have a self-administration of medication assessment, physician authorization, IDT review, or care plan supporting self-administration. The facility’s policy required IDT assessment and periodic re-evaluation, evaluation of cognitive, communication, visual, and physical ability, chart notation, nurse instruction, MAR documentation of self-administered doses, compliant medication storage, and care plan notation, and the DON confirmed the policy was not followed.
MDS Assessment Not Accurately Coded for Active Diagnosis
Penalty
Summary
The facility failed to ensure the MDS was accurately coded for one resident, Resident 107, because the annual assessment did not reflect the resident’s active diagnoses under Section I, Active Diagnoses. Resident 107’s admission record showed diagnoses including end stage renal disease, anxiety disorder, and anemia. During interview and record review, the DON reviewed the annual MDS assessment dated August 8, 2025, and Section I, Psychiatric/Mood Disorder, showed Anxiety Disorder left blank, indicating the resident did not have an active diagnosis of anxiety disorder. During the concurrent interview, the DON verified that the MDS was coded incorrectly and stated that Resident 107 did have a diagnosis of anxiety disorder. The facility’s policy and procedure titled Resident Assessment Instrument/MDS 3.0, dated February 2025, was also reviewed, and it stated the purpose was to ensure accurate, timely, and compliant completion of MDS assessments. The DON stated the policy and procedure was not followed.
PASARR Screening Not Completed for Resident Staying Beyond 30 Days
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one of five sampled residents after the resident stayed more than 30 days in the facility. Resident 1 was admitted with diagnoses including right lower extremity DVT, pneumonia, and cerebral infarction. The admission record showed the resident was admitted on [DATE], and the PASARR assessment dated [DATE] showed a Level I screening result of Exempted Hospital Discharge, meaning the resident did not have a PASARR screening before hospital discharge and should have had one completed if the resident remained in the skilled nursing facility beyond 30 days. During a concurrent interview and record review on June 3, 2026, the MDS nurse reviewed the PASARR Level I screening result dated April 15, 2026 and stated she did not know the meaning of Exempted Hospital Discharge. She acknowledged the PASARR screening should have been completed because Resident 1 stayed 49 days in the facility, and stated it was not done. During a concurrent interview and record review on June 4, 2026, the DON reviewed the facility's PASRR policy dated February 2026, which stated a PASARR form shall be completed on every resident upon admission unless it is done by the hospital. The DON stated the policy was not followed and that the PASARR screening should have been done.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, with 3 medication errors identified in 36 observed opportunities for an overall error rate of 8.3 percent. The errors involved two residents and were identified through observation, interview, and record review during the survey. Resident 123, who was admitted with diagnoses including noninfective gastroenteritis, colitis, protein-calorie malnutrition, and adult failure to thrive, had an order for Omeprazole 20 mg by mouth in the morning for GI prophylaxis. During observation, an LVN stated the medication was unavailable because it had not been delivered by the pharmacy and was not in the medication room. The eMAR note documented that Omeprazole was awaiting pharmacy, and the DON confirmed that Resident 123 missed one dose of Omeprazole. Resident 45, who had diagnoses including fracture of the left femur, chronic kidney disease stage 2, and atherosclerotic heart disease, had an order for Vitamin D3 1000 units daily and Vitamin B12 500 mcg daily. During medication administration observation, an LVN gave Vitamin D3 5000 IU instead of the ordered 1000 units, and later stated the wrong dose had been given. The same resident’s Vitamin B12 was scheduled for 9:00 AM but was not available in the medication cart at that time; it was documented as administered at 10:50 AM. The DON confirmed the facility’s medication administration policies were not followed.
Unsecured Medications Left at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were stored securely when Fluticasone Propionate/Salmeterol inhaler, Nystatin cream, and Diclofenac Sodium topical gel were found unattended and readily accessible on Resident 47’s bedside table. Resident 47 was admitted with COPD, GERD, and a right shoulder fracture, and her MDS dated May 19, 2026, showed a BIMS score of 12, indicating moderate cognitive impairment. During an interview on June 1, 2026, Resident 47 confirmed she was still using the three medications observed on the bedside table. During a concurrent observation and interview, LVN 5 confirmed the inhaler had a handwritten open date of May 16, 2026, with 52 doses remaining out of 60 doses, and acknowledged that the Diclofenac gel, Nystatin cream, and inhaler belonged to Resident 47 and that it was unsafe to leave medications unattended on the bedside table. Record review showed the inhaler was ordered for bronchospasm related to COPD, Diclofenac Sodium external gel was ordered as needed for pain to the shoulder, and Nystatin was ordered for rash and later discontinued. During interviews on June 4, 2026, the DON confirmed the Nystatin medication observed on the bedside table had been discontinued and acknowledged it should not have been left unattended in the resident’s room. The facility policy stated medications and biologicals are to be stored safely, securely, and properly, accessible only to authorized personnel, and the DON stated the policy was not followed by staff.
Failure to Disinfect Reusable Medication Tray Between Residents
Penalty
Summary
The facility failed to ensure effective infection control practices were followed for three residents when an LVN did not clean and disinfect a reusable medication tray between medication administrations. During an observation in one resident's room, after giving medication, the LVN placed a used medication cup, a used spoon with applesauce on it, and a used water cup back onto the medication tray and returned it to the medication cart. The LVN discarded the used items, removed gloves, and performed hand hygiene, but did not clean or disinfect the medication tray before beginning to prepare medications for another resident on the same tray. In a subsequent observation in another resident's room, the LVN placed medication in a cup on the same uncleaned medication tray, assisted the resident with taking the medication and water, and returned the used medication cup to the tray before returning it to the cart. In a third observation, the LVN discarded the prior resident's medication cup and then prepared medication for a third resident without disinfecting the tray, placing two medication cups and a water cup directly onto it. During interview, the LVN stated infection control practices must include disinfecting reusable supplies between residents and acknowledged the medication tray should have been cleaned and disinfected after giving medication to one resident and before preparing medication for another resident. The DON later confirmed the facility policy required routine cleaning and disinfection of noncritical items between each resident use and stated the policy was not followed.
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.
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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) |
|---|---|---|---|---|
| Medical Center Convalescent Hospital | 0.2 mi | ★★★★★ | 13 | 0 |
| Valley Healthcare Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Waterman Canyon Post Acute | 0.5 mi | ★★★★★ | 1 | 0 |
| Haven Post Acute | 1.6 mi | ★★★★★ | 2 | 0 |
| Del Rosa Villa | 1.8 mi | ★★★★★ | 13 | 0 |
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