Arrowhead Post Acute LLC

Inspectors wroteBased on observations, staff interview, and review of the facility's policy titled, Ice Machines and Ice Storage Chests F880, the facility failed to ensure food items in the walk-in cooler were labeled and dated, maintain the kitchen in a clean and sanitary manner, and keep the ice scoop clean and covered. The deficient practices had the potential to place the 77 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to maintain a safe, functional, and sanitary environment in 16 of 47 resident rooms (rooms 101, 104, 105, 106, 125, 128, 129, 131, 132, 133, 137, 138, 139, 142, 143, 147), the main dining room, and the right and left wing day rooms. These failures had the potential to lead to injury or accidents, the spread of infection, or feelings of discomfort and dissatisfaction among residents.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to maintain an effective pest control program for seven of 34 sampled residents' rooms (R) (R71, R15, R70, R59, R52, R184, and R20). This failure had the potential to lead to further pest infestation in the facility and feelings of discomfort or spread of infection among the residents.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure three of 34 sampled residents (R) (R59, R65, and R76) reviewed for residents' rights were able to exercise their right to vote in elections through absentee ballots or other authorized methods.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to ensure one of 34 sampled residents (R) (R4) was invited to participate in care plan meetings. This had the potential to cause R4's wishes and goals for her stay at the facility to be unmet.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure one of five residents (R) (R64) reviewed for Advance Directives out of a total sample of 34 residents had the correct code status, which identified her wishes in the event of a medical emergency. The failure placed residents at risk of not having their end-of-life wishes honored.

Inspectors wrote2. Review of the R29's Face Sheet, located in the Profile tab of the EMR, revealed R29 was admitted to the facility on [DATE]. Review of R29's most recent annual MDS with an ARD of 7/17/2024, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated R29 was cognitively intact for decision-making. This MDS assessment further indicated R29's vision was severely impaired and had no impairment in range of motion in the upper or lower extremities. Review of the MDS section titled Preferences for Customary Routine and Activities lists a series of questions about Activity Preferences. R29 provided the answer of Very Important for the following questions: [...]

Inspectors wrote2. Review of R27's admission Record located in the EMR under the Profile tab, revealed an admission date of 02/07/14 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the left dominant side. Review of R27's most recent annual MDS located in the EMR under the MDS tab with an ARD of 8/17/24, revealed the resident had severely impaired cognitive skills for daily decision making. R27 had limitations in range of motion, had impairment on both sides in the upper and lower extremities, and was dependent on staff for all functional abilities. Review of the EMR under the Orders tab revealed that there was no current physician's order for the use of heel protectors. Review of the EMR under the Care Plan tab revealed a care plan initiated on 02/10/22 with a focus stating: [...]

Inspectors wroteBased on observation, record review, and policy review, the facility failed to ensure one of six residents (R) (R8) reviewed for assistance with Activities of Daily Living (ADLs), out of a total of 34 sampled residents, received assistance with ADLs. This failure had the potential to cause skin breakdown, urinary tract infection, or discomfort for R8.

Inspectors wrote3. Review of the R29's Face Sheet, located in the Profile tab of the EMR, revealed R29 was admitted to the facility on [DATE]. Review of R29's most recent annual MDS with an ARD of 7/17/2024, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated R29 was cognitively intact for decision-making. This MDS assessment further indicated R29's vision was severely impaired and had no impairment in range of motion in the upper or lower extremities. Review of the MDS section titled Preferences for Customary Routine and Activities lists a series of questions about Activity Preferences. R29 provided the answer of Very Important for the following questions: [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure that one of three residents (R) (R27) reviewed for pressure ulcers out of a total sample of 34 sampled residents was provided with a pressure-relieving device to relieve pressure between bony prominences. This failure had the potential to place R27 at risk for pressure ulcer development.

Inspectors wrote2. Review of R8's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility with diagnoses that included seizures, aphasia, and deaf non-speaking. Review of R8's quarterly MDS, with an ARD of 3/13/2025 and located under the MDS tab of the EMR for Section C (Cognitive Patterns) revealed, he scored zero out of 15 on the BIMS, indicating severely impaired cognition; Section D (Mood) revealed, R8 did not exhibit any mood or behavioral symptoms, and Section N (Medications) revealed, he used antianxiety medication. Review of R8's Care Plan, dated 4/27/2025 and located under the Care Plan tab of the EMR, revealed, [R8] uses anti-anxiety medications r/t [related to] anxiety disorder. The approaches included Give anti-anxiety medications ordered by physician. [...]

Inspectors wroteBased on observations, interviews, and review of the facility's policies titled Storage of Medications F 761 and 5.3 Storage and Expiration Dating of Medications and Biologicals, the facility failed to remove expired medications from one of two medication carts located on the Left Wing. This deficient practice had the potential to place the residents at risk of receiving medications with altered effectiveness.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled Evaluations, the facility failed to ensure one of one resident (R) (R184) reviewed for rehabilitation out of a sample of 34 residents received timely speech therapy services when ordered to address a swallowing problem. This failure had the potential to place R184 at risk of a decline in swallowing function and dissatisfaction with pureed meals, which could contribute to weight loss or malnutrition.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy titled Guidelines for Charting and Documentation, the facility failed to ensure the clinical record accurately reflected the status of one of 34 residents (R) (R8) related to use of a wander guard (departure alert system). This failure created a misrepresentation of care being provided.

Inspectors wroteBased on record review, staff interview, and review of facility's policy titled Infection Control Program - Antibiotic Stewardship, the facility failed to ensure that antibiotics were not used without the presence of a diagnosed infection for one of three residents (R) (R53) reviewed for antibiotic stewardship out of a total sample of 34 residents. The failure had the potential to lead to increased antibiotic resistance or adverse side effects related to unnecessary antibiotic usage.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain proper ventilation in six resident rooms and on the main hall of the facility to ensure adequate air circulation and environmental hygiene. This failure had the potential to contribute to residents' discomfort and poor air quality for all 80 residents currently residing in the facility.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Vaccination of Residents, Including Influenza, Pneumococcal, Respiratory Syncytial Virus (RSV), and COVID-19, Reporting of, the facility failed to offer or provide documentation of consent or refusal of vaccinations for five of five residents (R) (R7, R14, R53, R66, and R72) reviewed for vaccination consents.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, F 625 Bed Hold, the facility failed to ensure a bed-hold policy upon transfer to the hospital for one of 35 sampled residents (R) (R79).

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, F 656, F 657, F 658 Comprehensive Care Plan, the facility failed to develop and implement a care plan for activities of daily living (ADL) for one of 35 sampled residents (R) (R8). The deficient practice had the potential for decline in R8's functional abilities.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to have an order for oxygen (O2) therapy for one of three residents (R) (R72) on oxygen therapy. The deficient practice had the potential to cause delayed treatment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure there was a clean, comfortable environment, as evidenced by dirty and stained walls, floors, privacy curtains and air conditioning vents and missing or broken floor tiles in resident rooms/bathrooms and common areas. These environmental concerns were observed in the corridors on two of two wings, in eight resident rooms, and in one day room.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to develop and implement comprehensive care plans for four (Residents #9, #22, #72, and #78) of 19 sampled residents whose care plans were reviewed.

Inspectors wroteBased on observations, interviews, record review, and review of the facility policy, the facility failed to maintain the dignity of a resident while in the dining area for one of two residents (Resident [R] #37) reviewed for dignity by not cutting their food or assisting during a meal and allowing the resident to eat with their fingers.

Inspectors wroteBased on observation, interviews, document review, and review of policy and procedures, the facility failed to ensure a resident's right for a homelike environment that meets the resident's needs, including a wheelchair, and access to a bathroom for two of nineteen residents (Resident #18 and Resident #39) reviewed for resident rights.

Inspectors wroteBased on resident and staff interviews, record reviews, and review of a facility policy, the facility failed to provide showers as planned and desired for one of two residents (Resident [R]#9) who was reviewed for choices for showers.

Inspectors wroteBased on staff and resident interview, record review, and facility policy review, the facility failed to notify a resident representative of missed dialysis appointments, change in condition and transfer to the hospital for one of two residents (Resident (R) #22) that received hemodialysis services.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a discharge summary was completed for one (Resident [R] #80) of one resident reviewed for discharge requirements. This had the potential to affect 11 residents with planned discharges from the facility.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to consistently provide nail care and oral care for one of three dependent residents (Resident [R] #22) observed for activities of living.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to document accurate intake of meals and percentage of nutritional supplement consumed for one of two residents (Resident #37) reviewed for nutrition.

Inspectors wroteBased on interviews and record review, the facility failed to maintain a Registered Nurse (RN) on duty for eight consecutive hours per day, seven days per week. This had the potential to affect all 80 residents.

Inspectors wroteBased on interviews, record review, and review of policy and procedures, the facility failed to ensure social services, including referrals to other facilities closer to a resident's family, were provided for one of three residents (Resident [R] #19) whose responsible party (RP) had requested a transfer.