Arrowhead Springs Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: During an observation on April 21,2025, at 10:21 AM, in Resident 54's room, Resident 54 was awake lying in bed, half of the mattress at the foot of the bed, was peeled and discolored. During a concurrent observation and interview on April 21, 2025, at 04:50 PM, with the Administrator (ADMIN), in Resident 54's room, the ADMIN stated, Oh, we need to change this mattress right now. The ADMIN stated, Resident 54 has [name of the insurance company] insurance and Admin was going to contact them (the insurance company) to replace the mattress. During a review of Resident 54's admission Record (contains medical and…

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 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. Findings: 1. During a Review of Resident 22's admission Record (contains demographic and medical information), it indicated Resident 22 was…

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 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. Findings: During a Review of Resident 22's admission Record (contains demographic and medical information), it indicated Resident 22 was admitted to the facility on [DATE], with diagnoses which included difficulty walking (trouble walking which may be due to weakness,…

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, 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. Findings: During a Review of Resident 58's admission Record (contains demographic and medical information), it indicated Resident 58 was admitted to the facility on [DATE], with diagnoses which included kidney transplant status (a transplanted kidney), congestive heart failure (a chronic condition where the heart doesn't pump blood as well as it should) and pancytopenia (a condition where all types of blood cells are low, reducing the body's ability to fight infection, carry oxygen and control bleeding, making any injury more serious). During a concurrent observation and interview on…

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, 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. Findings: During a review of Resident 74's admission Record (contains demographic and medical information), it indicated Resident 74 was admitted to the facility on [DATE], with diagnoses of acute chronic diastolic (congestive) heart failure (the heart can't pump blood well, so fluid can back up into the lungs, causing trouble breathing), paroxysmal atrial fibrillation (the heart has episodes of irregular beating) and muscle weakness (generalized) (when muscles are very weak and can make it hard to breathe deeply.) During a concurrent observation and interview on April 21,…

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, 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. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: urinary tract infection (urine infection), syncope and collapse (fainting, loss of consciousness), hypertension (high blood pressure), history of falling. During a concurrent interview and record review of Resident 1's Medical Record with Infection Prevention Nurse (IP), reviewed and verified the following: 1. admission Fall Risk assessment dated…

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, 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. Findings: During interview and Records Reviewed with (Resident 1,2, 3, and 4) indicates as followed: 1. During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to…

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 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. Findings: During a review of Resident 1 ' admission Record (general demographics) the document indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included age-related cataract (a condition of blindness), quadriplegia (a condition of loss of movement and feelings in both arms and legs, cerebral palsy (a condition that affects the movements and coordination) and history of falling (July 9, 2023). During an interview on October 22, 2024, at 12:15 PM, with the Certified Nursing Assistant (CNA 1), the CNA 1 stated, I usually call another CNA to help me change and turn her because she is not able to…

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, 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. This failure had the potential for staff to not identify that Resident 1 was on enhanced barrier precautions and required the use of a gown and gloves during high-contact resident care activities which increased Resident 1 ' s risk of either acquisition of or transmission of MDRO ' s. Findings: A review of Resident 1 ' s admission Record (contains medical and demographic information) indicated…

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, 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. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: fracture of T11-T12 vertebra (thoracic spine fracture), diabetes type II (body does not produce enough insulin, or resist insulin), obstructive sleep apnea (airflow blockage during sleep), hypertension (high blood pressure). During a review concurrent interview and record review of Resident 1's Medical Record with 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 observation, interview, and record review the facility failed to follow Its policy and procedure to provide Activities of Daily Living Services (ADLS) and ensure call lights are answered in timely manner for 4 of 5 sampled residents. (Resident's 2,3,4, and 5). This failure had the potential to place four clinically compromised Residents (Resident 2,3,4 and 5) health and safety at risk. When residents were left soiled, and their hygiene needs were not met. Findings: During a review of Resident 2's admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses to include, urinary tract infection (urine infection), multiple sclerosis (damage to nerves in brain and spinal cord), difficulty walking, hypertension (high blood pressure). During interview and observation on August 22, 2023, at 10:34 AM, with Resident 2, resident 2 states, The longest I have been in soiled bed is 7 hours on the night shifts, it's so uncomfortable. Some of 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.

Based 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. Findings: 1. During an observation and concurrent interview with the Dietary Services Supervisor (DSS) on May 23, 2022,at 10:10 AM, the six burner industrial stove was missing five plastic knobs that were used to turn on the burners and adjust the gas flow. The left front and rear middle pilot burners were not lit, the remaining four burners were lit with a low flame. According to the DSS, the cook grabs a plastic knob from another location and uses it on the missing knobs to turn on and adjust the gas for the burners. She stated that she was not sure why two of the burners were not lit. She stated that the cook uses a lighter and the knob to turn…

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 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. Findings: 1. A review of Resident 70's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of [DATE], with a diagnosis of chronic obstructive pulmonary disease (airway obstruction from the lungs), dysphasia (difficulty speaking), chronic respiratory failure with hypercapnia (not able to exchange oxygen due to not having enough oxygen in blood). A review of Resident 70's MDS, Minimum…

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 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. This failure had the potential to decrease in the range of motion and could have resulted in worsening of contractures (joint stiffness) and mobility for Residents 8 and…

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, 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. Findings: During a review of Resident 53's admission Record, indicated Resident 53 was initially admitted to the facility on [DATE], with a diagnosis of dysphagia ( difficulty swallowing ) and hemiplegia ( a condition, caused by a brain injury , that results in varying degrees of weakness, stiffness and lack of control in one side of the body) . During an observation on May 24, 2022 at 3:30 PM, Reident 53 was in bed and appeared to be sleeping, he was…

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, 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. Findings: During a review of Resident 53's clinical record, the admission Record [contains demographic and medical information], indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included heart failure, chronic respiratory failure, and diabetes mellitus (a chronic metabolic disease which results in elevated blood sugar…

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 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). Findings: During a review of Resident 72's clinical record, the admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on…

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 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). Findings: During a review of Resident 72's clinical record, the admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE], with diagnoses which included hemorrhagic disorder due to extrinsic circulating anticoagulants (bleeding disorder due to the use of anticoagulants), dependence on respirator (ventilator - a machine which aids…

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 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. Findings: During a review of Resident 34's clinical record, the admission Record [contains demographic and medical information], indicated the resident was admitted to the facility on [DATE], with diagnoses which included nontraumatic intracerebral hemorrhage (bleeding into the brain in the absence…

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, 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. This failure had the potential for the contamination of the environment and the spread of Candida Auris to the 88 vulnerable residents living within the facility who did not already have Candida Auris infection. Findings: During a review of Resident 83's clinical record, the admission Record [contains demographic and medical…

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.