Arrowhead Springs Healthcare

Inspectors wroteBased on interview and record review, 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 of four sampled residents (Resident 120, 121, and 122) when Resident 120, 121, and 122 did not receive written notification of their estimated out of pocket cost on the required Skill Nursing Facility Advance Beneficiary Notice of Non-coverage form (a form a facility gives a resident to let them know Medicare may stop paying for their stay or certain services). These failures had the potential to prevent residents from receiving the information necessary to understand their potential financial liability and make informed decisions regarding continued care. [...]

Inspectors wroteBased on interview and record review, the facility failed to update Pre-admission Screening and Resident Review (PASARR - a federally mandated program that requires all individuals seeking admission to a Medicaid-certified nursing facility to be screened to ensure individuals who are identified to have a significant mental illness (SMI), intellectual or developmental disability (I/DD)) are not inappropriately placed in nursing homes for long term care) for two of five sampled residents (Resident 17 and 76) for PASARR when: 1. Resident 17 did not have his diagnoses of post-traumatic stress disorder (PTSD - a mental health condition triggered by experiencing or witnessing a terrifying, shocking, or dangerous event) included in the PASARR assessment used to admit the resident into the skilled nursing facility.2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the appropriate treatment to three Residents (Resident 2, 13 and 24) fed by enteral means. The three Residents did not receive the correct volume of enteral feeding (liquid nutrition through a soft tube that goes directly into your stomach or small intestine) ordered by the physician when:Resident 4 did not receive the physician ordered volume of enteral feeding (75 mL (milliliter)/hr. (hour), or 300 mL) during the observation period of 6:00 am to 10:00 am on June 1, 2026. The Licensed Vocation Nurse (LVN-1) also did not know how much of the enteral feeding was infused during the prior shift for the dose period starting at 2:00 pm on June 1, 2026, until the start of her shift at 7:00 am which is necessary to ensure that Resident 4 received the full dose of 1500 mL. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was assessed and authorized to self - administered medications of 13 residents (Resident 47) reviewed for medication administration when three medications were found at the Resident 47's bedside within reach and readily accessible, without a completed self-administration of medications assessment (a clinical evaluation to determine if a resident can safely store, manage, and take their own medications independently or with minimal supervision), interdisciplinary team (IDT - a group of medical support professionals who work together to create and execute a patient - centered care plan) review, or physician authorization. This failure had the potential to result in improper medication use, medication errors and cause harm to Resident 47 due to unsupervised access to prescribed medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) assessments were accurately coded for one (1) of 26 residents (Resident 107) when Resident 107's assessment did not reflect the resident's status, care, and services in active diagnoses under Section I (Active Diagnosis section). This failure had the potential to cause inaccuracies in identifying Resident 107's care and support needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR - a federally mandated program that requires all individuals seeking admission to a Medicaid-certified nursing facility to be screened to ensure individuals who are identified to have a significant mental illness (SMI), intellectual or developmental disability (I/DD)) was completed for one of five sampled residents (Resident 1) for PASARR when Resident 1 stayed more than 30 days in the facility. This failure had the potential to result in Resident 1's condition not being identified prior to admission and the need for treatments and services not being accurately assessed, placing Resident 1 at risk for unmet needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent with three medication errors of 36 observed opportunities, affecting two on thirteenth observed residents (Resident 123 and 45), resulting in an overall error rate of 8.3 percent when:1. Resident 123 was not given Omeprazole (a medication used to reduce stomach acid) as ordered. This failure had the potential for Resident 123 to have increased stomach discomfort or increased stomach acid. 2. Resident 45 received Vitamin D3 (a vitamin that helps with strong bones, muscles, and the immune health) 5000 IU (International Units- unit of measurement) instead of Vitamin D3 1000 units (unit of measure), as prescribed by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and secure for one of 13 resident (Resident 47), when Fluticasone Propionate/Salmeterol inhaler (a medication used to help control and prevent symptoms of chronic obstructive pulmonary disease [COPD]), Nystatin cream (a medication used to treat fungal skin infections) and Diclofenac Sodium Topical gel (a medication used to relieve pain and inflammation) were found unattended and readily accessible on Resident 47's bedside table. This failure had the potential to result in improper medication use, medication errors, adverse drug reactions by Resident 47 or others. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed effective infection control practices for three (3) of 107 residents (Residents 60, 54, and 52) when one licensed vocational nurse (LVN 3) did not clean and disinfect a reusable medication tray (used to prepare and transport medication to residents) between medication administration. This failure had the potential for cross contamination (the transfer of harmful bacteria), which could expose residents to harmful organisms (capable of causing infection, illness, or adverse health effects) and lead to preventable healthcare associated infections (HAIs- infections that residents acquire while receiving care in a healthcare facility) for 107 highly vulnerable residents. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure proper disposal of garbage when one of two lids in the outside recycling receptacles was not closed and overflowing with trash. This failure had the potential to attract pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, supplies were kept in good condition for one out of twenty-five residents (Resident 54) when Resident 54's mattress was found peeled, discolored, and in disrepair. This failure had the potential for Resident 54 to experience physical discomfort, sleep disturbances, and increased risk of infections or skin breakdown.

Inspectors wroteBased on observation interview and record review the facility failed develop and implement comprehensive, person-centered care plans (a care plan that includes all the health problems, preferences and goals) for two of three residents (Residents 22 and 17) that were reviewed for care plans needs when: 1. Resident 22 did not have a care plan developed to address ongoing podiatry needs for long fingernails and toenails since admission, on October 4, 2024. 2. Resident 17 did not have a care plan developed for intravenous (IV) antibiotic therapy with Ceftazidime Intravenous Solution ( a strong antibiotic given through a vein (IV) that helps kill bacteria caused infection). These failures had the potential to result in unmet medical needs for Residents 22 and 17, and can cause delay in treatment and lack of coordinated care, placing Resident 22 and 17 at risk for complications.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide proper hygiene and grooming care (help with keeping the body clean and neat including cutting nails, brushing hair, shaving and general personal appearance) for one of eight residents (Resident 22) when Resident 22 had long thickened and yellow toenails curling over the tips on both feet, as well as long, untrimmed fingernails on both hands. This failure had the potential for Resident 22 to experience pain, skin breakdown, fungal infection (infection caused by germs [fungus] that grow on the skin or nails, in toenails, it can make them thick, yellow brittle and sometimes painful), refusal of mobility and negatively impacted Resident 22's dignity and quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the bilateral side rails (an adjustable metal or rigid plastic bars that attach to the bed) were in place for one of eight residents (Resident 58) reviewed for safety when a physician order to install bilateral side rails was not carried out for 37 days (March 17, 2025). This failure had the potential to place Resident 58 at risk for falls or injury.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain infection control practices for one of eight residents (Resident 74) when Resident 74's oxygen tubing (is a small, flexible plastic tube that connects an oxygen source [like a machine or a tank]) was found on the floor under the bed. This failure had the potential to spread infectious disease (disease cause by bacteria, viruses, fungi or parasite) to Resident 74.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents for one of three sampled residents Resident1 (R1) when: 1. Resident 1 fell out of bed, sent to acute hospital for open laceration to right side of head. 2. No floor mats at bedside as recommended. This failure contributed to Resident 1 sustaining an open injury to forehead and being set out to hospital for further evaluation and received staples.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its Activities of Daily Living ADLs policy and procedure for 4 of 10 sampled Residents (Resident's 1,2, 3 and 4) when: 1. Resident 1 used call light to get staff attention for help and assistance and it takes a 1 hour to answer and NOC shift doesn't even come at all. 2. Resident 2 was left soiled for a long period of time on NOC shift. 3. Resident 3 used call light needed assistance due to feelings of low blood sugar and waited 3 hours long to get assistance. 4. Resident 4 needed assistance with ADLS and wait time was well over an hour or closer to shift change. This failure had the potential to cause (Resident 1,2,3, and 4) health and safety to be at risk for skin break down when their care needs were not met.

Inspectors wroteBased on interview, and record review the facility failed to ensure that one of three sampled residents, (Resident 1) received treatment and care in accordance with professional standards of practice, when Resident 1 fell off the bed unto the floor during care by a Certified Nursing Assistant (CNA 2). This failure resulted in Resident 1 sustaining a laceration on her right eyebrow.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection prevention and control program when Resident 1, on enhanced barrier precautions (EBP - an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of multidrug resistant organisms [MDRO - bacteria that have become resistant to certain antibiotics]), did not have identifiable enhanced barrier precautions signage outside the resident ' s room in accordance with the facilities policy and procedure and Centers for Disease Control and Prevention (CDC) guidance. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and procedure for a thorough admission assessment when a surgical wound did not receive a treatment order on admission causing a delay in treatments for one of five sampled residents (Resident 1). This failure had the potential to place a clinically compromised Resident (Resident 1) health and safety at risk. When the surgical wound assessments and treatments to promote wound healing were started 4 days after admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to do maintenance on the stove in the kitchen on an annual basis per their policy , when two of the burners were not lit because the gas lines were clogged with grease/corrosion and five out of eight dials that function to turn on the burners and adjust gas flow were missing. This failure had the potential to cause a grease fire and put staff and 91 residents at risk.

Inspectors wroteBased on interview, and record review, the facility failed to discuss and provide information on advanced directives (a written statement of a person's wishes regarding medical treatment, should the person be unable to communicate with the doctor) for one of six sampled residents reviewed for advanced directives (Residents 70) when the Physician's Orders for Life Sustaining Treatment (POLST) for one resident (Resident 70) was not initiated upon admission. This failure had the potential to cause Resident 70's values and desires related to end-of-life care not to be carried out.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide appropriate treatment and services to increase range of motion or to prevent further decrease in range of motion for two of 11 sampled residents (Resident 8 and 52), when range of motion exercises and splints were not provided as per physician orders, by the restorative nursing assistants (RNA- certified nursing assistants specially trained to do range of motion and splints) 1. For Resident 8, Restorative Nursing Assistant (RNA-a certified nursing assistance with training on range of motion and the application of splints) services were not provided to resident as ordered by the physician, for the month of May 2022. 2. For Resident 52, Restorative Nursing Assistant services were not provided to the resident, as ordered by the physician, for the month of May 2022. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain acceptable parameters of nutritional status when Resident 53's enteral feeding (nutrition taken through a tube that goes directly to the stomach or small intestine) was not assessed correctly by the Registered Dietitian after re-admission to the facility from a hospital stay. This failure resulted in the Resident losing 3% of his body weight in one month after re-admission. Unintentional weight loss in the elderly population is associated with increased morbidity and mortality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an enteral nutrition container (container with liquid nutritional formula administered to a resident through a feeding tube inserted directly into the stomach) for one resident (Resident 53) was labeled with nurse initials and start time (time the feeding was started) as indicated in the facility's policy and procedure. This failure had the potential for the bottle to exceed the manufacturer's prescribed hang-time (the time a feeding is safe to use after opened), and for Resident 53 to not receive the prescribed amount of nutritional calories resulting in weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff identified an irregularity during medication administration and monthly drug regimen review for one of one residents (Resident 72) reviewed for anticoagulants (blood thinners) when it was not identified that the resident had a physician's order for heparin (an anticoagulant) to be administered intramuscularly (into the muscle tissue) instead of subcutaneously (into fatty tissue). Nursing staff administered the medication subcutaneously and did not identify the discrepancy, nor seek clarification from the physician regarding the route of administration. This failure had the potential for the resident to receive heparin intramuscularly which may have resulted in the formation of a hematoma (abnormal collection of blood outside of a blood vessel).

Inspectors wroteBased on interview and record review, the facility failed to ensure the monthly medication review was implemented per the facility's policy and procedure for one of six residents (Resident 72) reviewed for medication regimen review when the pharmacist failed to identify Resident 72's physician's order for heparin (an anticoagulant or blood thinner) was to be administered intramuscularly (into the muscle tissue) every 8 hours. This failure had the potential for the resident to receive heparin intramuscularly which may have resulted in the formation of a hematoma (abnormal collection of blood outside of a blood vessel).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician's Orders for Life Sustaining Treatment (a written medical order from a physician, nurse practitioner or physician assistant that specifies the type of medical treatment to provide an individual during serious illness) was signed by a physician, nurse practitioner, or physician's assistant, for one of six sampled residents investigated for advanced directives (Resident 52). This failure resulted in information and decisions determined on the POLST to not be an official physician's order which had the potential for the needs and desires regarding end-of-life medical treatment to not be carried out in accordance with the resident's request.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection control program to prevent the spread of infectious microorganisms when three staff members (Licensed Vocational Nurse 4 [LVN 4], Admissions Coordinator [AC], and Certified Nursing Assistant 2 [CNA 2]) did not follow precautions when they were observed to enter the room of a resident (Resident 83) on contact precautions (precautions intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment) for Candida Auris (a fungus capable of causing severe infection) and all three staff members did not have on a gown. [...]