Arrowhead Healthcare Center, LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control practices and sanitary environment were followed when: 1.physician's orders were not followed for Resident 53 and Resident 21, when the residents' oxygen nasal cannula tubing (device used to deliver oxygen into the nose via a tube) and humidifier (bottle filled with distilled water that attaches to an oxygen concentrator or tank to add moisture to the oxygen) were found unlabeled and undated2. Three Hoyer lift (a mechanical lift) slings (strong, fabric harnesses that securely hold a person with limited mobility while a mechanical lift moves them) were observed hanging from the exterior bars outside the laundry room windows.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of five rooms (each with four resident beds per room) had the minimum required square footage for each resident. This failure had had the potential for increased risk of accidents and injuries to occur within the room as a result of limited space for wheelchair and Hoyer lift access (a mechanical device that helps move people with limited mobility), limited space to accommodate resident care activities, increased risk for falls, and a potential delay in the evacuation of residents during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of 18 sampled residents (Resident 4) when Resident 4's urinary collection bag (bag which collect and hold urine) was found not covered with a dignity bag (a drainage bag holder used to cover and hold the catheter drainage/collection bag, so it is not visible). This failure resulted in Resident 4's urine being visible to residents, staff, and visitors, which compromised his privacy and diminished his dignity, self-worth, and sense of respect.

Inspectors wroteBased on interview, and record review, the facility failed to ensure nursing staff followed a physician's order for hypoglycemia (low blood sugar) management for one of one sampled residents (Resident 43) reviewed for insulin (medication used to help lower blood sugar levels), when on multiple occasions, staff did not document a required repeat blood sugar check after the Resident 43's initial blood sugar was below 70 milligrams per deciliter (mg/dl). This failure resulted in Resident 43 to not receive care and monitoring of blood sugar levels as ordered by the physician and for Resident 43 to experience hypoglycemia without staff knowledge or intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 6) reviewed for pressure ulcers (injury to skin and underlying tissues that develops as a result of prolonged pressure, shear, or friction) had a low air loss mattress (LAL mattress - a specialized mattress which is air filled and is designed to help prevent and treat pressure ulcers) programmed to the correct weight as ordered by the physician. This failure resulted in the low air loss mattress to not have the most therapeutic effect for the prevention and treatment of pressure ulcers and for Resident 6 to have increased risk for the development of new pressure ulcers and a delay in wound healingFindings: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for one of 18 sampled Residents (Resident 4) when: 1. Urinary collection bag was not changed every Sunday and PRN (as needed) according to physician's orders. 2. Suprapubic catheter (a tube inserted into the bladder through a small abdominal incision, rather than the urethra, to drain urine) was not flushed with 60 cc (cubic centimeter: a unit of measurement) normal saline (a solution used for flushing suprapubic catheter) according to physician's orders This failure resulted in Resident 4's urinary drainage bag not being flushed and changed for several months, placing Resident 4 at risk for developing an urinary tract infections and causing discomfort and decline in Resident 4's health and well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff were competent in the monitoring of a dialysis access sites for one of one sampled resident (Resident 31) when multiple nursing staff were documenting Resident 31 had bruit (a whooshing or humming sound heard through a stethoscope placed over a fistula [surgically created connection between and artery and a vein], and thrill (a vibration or buzzing sensation felt under the skin when you lightly place your fingertips over a fistula. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 5 sampled residents (Resident 5) Metformin (a medication used for the treatment of high blood sugar) was administered as prescribed by the physician when the medication was administered without food. This failure had the potential for Resident 5 to have adverse side effects including gastrointestinal intolerance (the body's inability to properly digest or break down certain foods or substances, leading to uncomfortable digestive symptoms) and hypoglycemia (occurs when the blood sugar level drops below 70).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device that allows patients to communicate with nursing staff when they need assistance) was within residents' reach for two of six sampled residents (Resident 5 and 9) when: 1. For Resident 5, the call light was located on the floor on resident's right side of the bed and unreachable by the resident. 2. For Resident 9, the call light was wrapped around the feeding pump located on a pole away from resident's reach. This failure had the potential to placed Resident 5 and 9 at risk for their safety and well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was available onsite at least eight (8) hours a day, seven (7) days a week for 58 Residents from March 1, 2025, through April 10, 2025, when the facility did not have RN onsite for 3 days. This failure had a potential to negatively affect Residents overall health and safety by not having RN oversight and assessment in a universe of 58 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections, in a universe of 55 residents (Residents 1 to 55), when: 1. The facility did not conduct an annual review of its infection control program's policies and procedures (P&P) and update their program, as necessary. This failure had the potential to cause the facility to be out-of-date with current best practices and overlook potential gaps in their procedures. 2. Laundry staff (LS 1) did not follow the manufacturer's guidelines for the disinfectant used to disinfect laundry carts and dirty laundry barrels. Housekeeping staff (HS 1) did not follow the manufacturer's guidelines for the disinfectant used to disinfect resident rooms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for four of nineteen sampled residents (Residents 25, 27, 32, and 56) when: 1) Resident 25's RAI-MDS assessment dated [DATE], incorrectly indicated Resident 25 had only minimal hearing loss, and did not have a hearing aid. 2) Resident 27's RAI-MDS assessment dated [DATE], incorrectly indicated Resident 27 was not considered Pre-admission Screening and Resident Review (PASRR) level 2 by the state. 3) Resident 32's RAI-MDS assessment dated [DATE], incorrectly indicated Resident 32 received insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: a. Walk in refrigerator and freezer temperatures were not being monitored daily. b. A kitchen staff was observed working in the kitchen without a hair net. c. Shelves in the walk-in refrigerator had black residue on them where food was stored. These failures had the potential for bacteria to growth and cause foodborne illness in a highly susceptible population of 49 residents who received food and beverages from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was free of pests, when a cockroach was observed on the wall behind the steam table (a type of food-holding equipment designed to keep hot foods at a safe holding temperature). This failure had the potential to cause contamination of food and beverage for 49 residents who receive food and beverage from the kitchen, potentially leading to a resident infection.

Inspectors wroteBased on interview, and record review, the facility failed to provide evidence staff discussed with one of nineteen sampled residents (Resident 32) whether the resident had an existing advance directive (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) and was educated on his rights to establish a new advance directive if desired. This failure had the potential for Resident 32 to receive end of life care not in accordance with his wishes and for life sustaining measures to be rendered against what the resident wanted.

Inspectors wroteBased on interview, and record review, the facility failed to provide two of three sampled residents (Residents 17 and 28) with beneficiary liability protection notifications (A notification letter which explain resident rights regarding financial liability and the right to appeal) when: 1) Resident 17 was not provided with estimated costs on the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN - informs the resident about potential non-coverage and the option to continue services with the resident accepting financial liability for those services). 2) Resident 28 was not provided with estimated costs on SNF ABN and the Notice of Medicare Non-Coverage (NOMNC -informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization) was not provided to the resident at least two days before the end of a Medicare covered Part A stay. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident representative was notified of transfer in writing for one of 20 sampled residents (Resident 17). This failure had the potential to cause confusion about the transfer process and possibly leave the resident and the resident representative unable to make an informed decision about the transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 51) reviewed for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) received care and services for skin breakdown as was specified in the resident's care plan (an individualized plan for the medical care of a resident) and physician's orders when: -Resident 51's low air loss mattress (a mattress that uses air to help prevent and treat pressure wounds, and to regulate temperature and moisture levels) was not set to the correct pressure as specified by physician orders. -Resident 51 did not have on heel protectors [device that provides cushioning, support, and pressure relief to the heel] while in bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 37) reviewed for accidents had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) next to her bed as was specified in the resident's care plan (an individualized plan for the medical care of a resident). This failure had the potential for Resident 37 to sustain a serious injury during a fall in which the severity of the injury may have been lessened if the fall mat had been in place.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of five rooms (each occupied by four residents per room) had the minimum required square footage for each resident. This failure had had the potential for increased risk of accidents and injuries to occur within the room as a result of limited space for wheelchair and Hoyer lift access (a mechanical device that helps move people with limited mobility), limited space to accommodate resident care activities, increased risk for falls, and a potential delay in the evacuation of residents during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure daily staffing information was posted in a resident accessible area within the facility. This failure resulted in the inability of all 55 residents in the facility to have access to information regarding the staffing levels of licensed and unlicensed staff directly responsible for providing them care within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the results of the facility's most recent survey in a place readily accessible to residents, in a universe of 55 residents (Residents 1 to 55), when the survey results were posted in a lobby area whose residents' lobby access door was set to remain locked at all times. This failure had the potential to cause the residents' inability to read the survey results and assess areas like safety, staff competency, and compliance with regulations, which directly impacts their well-being and quality of life within the skilled nursing facility.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for 2 (Resident #2 and Resident #27) of 2 sampled residents reviewed for beneficiary notices.