Center At Arrowhead, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility policy, the facility failed to maintain infection prevention and control when delivering meal trays, providing foley catheter care for one of one sampled resident's (#9), and failing to consistently implement tracking and trending of their infection prevent and control program. The deficient practice could result in transmission of infection within the facility. -Regarding delivering of meal trays: Observations were conducted on April 30, 2025 of a Certified Nursing Assistant (CNA/staff #200) delivering in-room lunch meal trays to four residents on enhanced barrier precautions (EBP). The following was observed: -The CNA entered the first room, moved items on the bedside table and placed a meal tray on a bedside table, and exited the room without sanitizing her hands. -The staff member picked up a meal tray from the dietary cart and entered a second room without sanitizing her hands prior to entering the room. The staff member placed the meal tray on the bedside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interviews, policy review and Center for Disease Control (CDC) guidelines, the facility failed to consistently implement tracking and trending of their antibiotic stewardship program. The facility census was 79 residents. This deficient practice could result in improper antibiotic use and adverse outcomes to residents. Findings include: On May 1, 2025 at 11:35 AM, an interview was conducted with the Assistant Director of Nursing (ADON/staff #54) and the Regional Clinical Director (RCD/staff #205). The ADON and the RCD explained that the ADON was in the process of completing her training as the Infection Preventionist (IP). It was further explained that the previous IP (staff #69) was assisting the ADON with IP tasks approximately three to four hours per week. During the interview on May 1, 2025, the Infection Control Logs for January 2025 through April 2025 were reviewed with the RCD and the ADON. Resident names, types of infections and antibiotics used were listed on the log. However, there was no evidence of trending the information found on the logs.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that one resident (# 207) was administered medications in accordance with physician's orders. This deficient practice can result in diminished quality of life, and suboptimal clinical outcomes. Findings include: Resident #207 was admitted to the facility August 12, 2024 for a 5-day respite for hospice care with diagnoses that included Cerebrovascular disease, sequelae of cerebral infarction, hypertension, anxiety disorder, atrial fibrillation & depression. A hospice order summary dated August 12, 2024 revealed that the resident was prescribed Lactaid, Glucerna and sliding scale insulin instruction. Review of the August 2024 Medication Administration Record and the Treatment Administration Record revealed insulin was not administered and that fasting or random blood sugars were not completed during the 5-day respite period, that the resident was in the facility. A progress note dated August 12, 2024, indicated that medications to include medication administration times…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and facility policy, the facility failed to ensure medications were not left at the bedside for one of 16 sampled residents (#404). The deficient practice could result in medications not being administered correctly, or medications not taken as ordered by the provider. Findings include: Resident #404 was admitted on [DATE] with diagnoses that included fracture of fourth lumbar vertebra and subsequent encounter for fracture with routine healing. During an initial observation conducted on April 29, 2025 at 09:30 AM, of Resident #404's room, a tube of barrier cream and anti-fungal powder were observed on the resident's bedside table unattended. A second observation conducted on April 29, 2025 at 10:45 AM., revealed a tube of barrier cream and anti-fungal powder on the bedside table unattended. Review of physician orders revealed: barrier cream to coccyx and buttock area every shift and PRN dated February 22, 2025. Further review of physician orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to ensure the daily nurse staffing information was complete and accurate for actual hours worked for licensed and unlicensed direct care nursing staff. The deficient practice could result in residents, representatives, and visitors not being informed of accurate and current staffing information in the facility. Findings include: Review of the facility's daily nurse staffing forms for the dates of February 14, 2025 through February 18, 2025 and April 25, 2025 through April 27, 2025 revealed no evidence of actual hours worked by licensed and unlicensed staff. During an observation conducted on April 29, 2025 at 9:07 AM, the daily nurse staff posting form was displayed at the front information desk and form did not include the actual hours worked by licensed and unlicensed nursing staff. An interview was conducted with the Staffing Coordinator (staff # 73) on May 1, 2025 at 1:25 PM who stated that she is responsible for ensuring the daily nurse staffing information is accurate and posted. She stated that she had not been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#6) was reported to the State Agency. The deficient practice places the resident at risk for continued abuse. Findings include: Resident #6 was admitted to the facility on [DATE], with diagnoses of acute respiratory failure with hypoxia, enterocolitis due to clostridium difficile, sepsis, depression and low back pain. A review of the Resident #6 admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired. In addition, Resident #6 mostly required assistance with everyday activities. A review of the care plan initiated on January 24, 2024 revealed a need assistance with transfers and toileting related to impaired mobility secondary to weakness and debility. The interventions included check frequently and assist with toileting as needed, keep call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (#55) receive trimming of toe nails. The deficient practice could result in resident discomfort with pain and infection. Findings include: Resident # 55 was admitted to facility on January 9, 2024 with diagnosis included unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing, subsequent encounter, sepsis, unspecified organism, contusion of left elbow, subsequent encounter, essential (primary) hypertension, alcohol abuse, uncomplicated, gastro-esophageal reflux disease without esophagitis, muscle weakness (generalized), difficulty in walking, not elsewhere classified. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The MDS also indicated that the resident was dependent on toileting and lower body…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, observation of current practice, staff interviews, and facility documentation and policy review, the facility failed to ensure wound assessment was completed for one of 3 sampled residents (#1). The deficient practice could result in resident not receiving appropriate treatment and developing or worsening or wound. Findings include: Resident #1 was admitted on [DATE] with diagnoses of fractured left femur, essential hypertension, chronic obstructive pulmonary disease, diabetes mellitus type II, muscle weakness, and difficulty walking. The admission progress notes of July 7, 2023 revealed the resident arrived at the facility and had an immobilizer. The nursing comprehensive admission data collection tool dated July 7, 2023 revealed the resident had small surgical site pin hole in the left knee, 36 staples, minimal upper extremity bruising, bruising to the left thigh, and four sites of bruising on the left foot. Per the documentation Braden Scale score was 15, indicating the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and policy, the facility failed to ensure provision of Activities of Daily Living (ADL) care was provided to one resident (#112). The sample size was four residents. The deficient practice could result resident needs being unmet. Findings include: Resident #112 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer, Alzheimer's disease, muscle weakness, and difficulty walking. Review of a nursing note dated September 8, 2021 included an admitting diagnosis of weakness and that the resident needed substantial/maximal assistance with toileting hygiene. The resident's ADL care plan dated September 7, 2021 revealed an actual/potential decline in ability to perform ADLs. Interventions included to provide assistance as needed with grooming, bathing, and personal hygiene and to assist with ADLs as needed. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 9 on the Brief Interview for Mental Status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and policy, the facility failed to ensure one resident (#113) was provided wound care and treatment per physician's orders. The sample size was two residents. The deficient practice could result in delayed wound healing. Findings include: Resident #113 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis left ankle and foot, status post-surgical amputation, gangrene, peripheral vascular disease, and type two diabetes mellitus. Review of a nursing note dated July 18, 2021 included that the resident had a left great toe amputation. The resident's skin care plan, dated July 18, 2021, revealed the resident had a surgical wound related to a left toe amputation. The interventions included dressing changes per physician's orders and to monitor the incision daily and as needed. A wound care consultation dated July 20, 2021 included that the resident had a left great toe amputation with a surgical incision. The wound had wet eschar along the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and policies, the facility failed to ensure one resident (#113) was provided pressure ulcer care and assessment per physician's orders. The sample size was two residents. The deficient practice could result in delayed wound healing. Findings include: Resident #113 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of the left ankle and foot, status post-surgical amputation, gangrene, peripheral vascular disease, and type two diabetes mellitus. The resident's skin care plan, dated July 18, 2021, revealed a potential for skin breakdown due to decreased mobility. The interventions included conducting a Braden scale every week, skin evaluation as ordered, and dressing changes/treatments per physician's orders. Review of a wound care evaluation dated July 20, 2021 included the resident was admitted with an unstageable left heel pressure ulcer which measured 0.8 centimeters (cm) long by 0.9 cm wide. The wound bed was noted to contain eschar.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of hospital records, interviews, and policies, the facility failed to ensure one resident (#162) received appropriate catheter care and services. The sample size was one resident. The deficient practice could increase the risk for catheter-related injuries. Findings include: Resident #162 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, chronic obstructive pulmonary disease, and Benign Prostatic Hyperplasia (BPH). A urinary catheter care plan dated December 12, 2019 related to BPH with obstruction had a goal for no complications related to the catheter. An intervention included catheter care as ordered by the physician and as needed. A Nurse Practitioner (NP) progress note dated December 30, 2019 at 12:56 p.m. included that the resident's urinary catheter was patent and draining clear, light yellow urine. The note indicated that bladder training would be started that day to remove the catheter. A physician's order dated December 30,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility documentation, interviews, and policy, the facility failed to ensure residents and/or their representatives/family were notified of a confirmed case of COVID-19 within the required timeframe. The facility census was 46 residents. The deficient practice could result in residents and/or their representatives being unaware of the COVID-19 status in the facility. Findings include: Review of facility documentation revealed that one resident had tested positive for COVID-19 on November 5, 2022. Her symptoms included fatigue and a cough. The resident was put on quarantine on the same date. An interview was conducted with the representative of resident #29 on November 7, 2022 at 12:13 p.m. She stated that she have not been notified that any residents in the facility have COVID-19. In an interview with a family member of resident #165 on November 7, 2022 at 2:45 p.m., she said that the resident had received a phone call that morning to notify him that there was an active COVID-19 case in the building. During an interview with the representative of resident #21 on November…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.