Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
58 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Census: 58
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to assess compliance with staffing requirements, specifically to verify that a Registered Nurse (RN) was available onsite at least eight hours a day, seven days a week.
Findings
The facility failed to ensure an RN was onsite for three days between March 1, 2025, and April 10, 2025, including the day of inspection, potentially affecting the health and safety of 58 residents due to lack of RN oversight and assessment.
Deficiencies (1)
Failure to have a registered nurse on duty at least eight hours a day, seven days a week.
Report Facts
Days without RN onsite: 3
Resident census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admin 1 | Administrator | Interviewed regarding RN staffing and timecards |
| DON 1 | Director of Nursing | Full-time RN absent due to Covid, only full-time RN on staff |
| RN 1 | Registered Nurse | Part-time RN scheduled Mondays and Fridays |
Inspection Report
Routine
Census: 55
Deficiencies: 12
Date: Dec 19, 2024
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident rights, care planning, infection control, food safety, room size, staffing, and other regulatory requirements at Arrowhead Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to post survey results accessibly, incomplete advance directive discussions, inaccurate beneficiary liability notifications, failure to notify resident representatives in writing of transfers, inaccurate resident assessments, inadequate pressure ulcer care, lack of fall mats, failure to post nurse staffing information accessibly, food safety violations, infection control program deficiencies, inadequate resident room sizes, and pest control issues.
Deficiencies (12)
Failed to post the facility's most recent survey results in a place readily accessible to residents due to locked lobby access.
Failed to provide evidence staff discussed advance directives with Resident 32 and failed to complete required forms.
Failed to provide beneficiary liability protection notifications with estimated costs to Residents 17 and 28.
Failed to notify Resident 17's representative in writing of transfer.
Failed to accurately code Resident Assessment Instrument-Minimum Data Set (RAI-MDS) for four residents (25, 27, 32, 56).
Failed to provide appropriate pressure ulcer care for Resident 51 including incorrect mattress pressure setting and lack of heel protectors.
Failed to ensure Resident 37 had a fall mat next to bed as specified in care plan.
Failed to post daily nurse staffing information in a resident accessible area.
Failed to store, prepare, distribute, and serve food in accordance with professional standards including lack of temperature monitoring, staff not wearing hair nets, and dirty refrigerator shelves.
Failed to maintain an effective infection prevention and control program including outdated policies, improper disinfectant use, and failure to wear gowns when required.
Failed to ensure five rooms housing four residents each met minimum required square footage per resident.
Failed to maintain a pest control program resulting in a cockroach observed in the kitchen.
Report Facts
Residents affected: 55
Residents affected: 19
Residents affected: 20
Residents affected: 49
Daily room rate: 325
Rooms measured: 5
Residents per room: 4
Residents requiring Hoyer lift: 10
Residents with wheelchairs: 9
Residents with Geri chairs: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNS 1 | Registered Nurse Supervisor | Interviewed regarding survey results posting and advance directive documentation |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding survey results posting and fall mat absence |
| Admin | Administrator | Interviewed regarding survey results posting, transfer notification, room size, and staffing posting |
| DON | Director of Nursing | Interviewed regarding advance directives, pressure ulcer care, fall mat, staffing posting, and assessment accuracy |
| SSD | Social Services Director | Interviewed regarding advance directive documentation and transfer notification |
| BOM | Business Office Manager | Interviewed regarding beneficiary liability notifications |
| MDSN | Minimum Data Set Nurse | Interviewed regarding assessment accuracy |
| CNA 5 | Certified Nursing Assistant | Observed and interviewed regarding pressure ulcer care |
| DSD | Director of Staff Development | Interviewed regarding nurse staffing posting |
| DS | Dietary Supervisor | Interviewed and observed regarding food safety and pest control |
| HS 1 | Housekeeping Staff | Observed and interviewed regarding infection control cleaning practices |
| LS 1 | Laundry Staff | Observed and interviewed regarding laundry disinfection practices |
| IP | Infection Preventionist | Interviewed regarding infection control program and food safety |
| MS | Maintenance Supervisor | Measured resident rooms |
| RR 1 | Resident Representative | Interviewed regarding transfer notification |
| MDS nurse | MDS Nurse | Interviewed regarding assessment coding errors |
Inspection Report
Deficiencies: 1
Date: Oct 18, 2023
Visit Reason
The inspection was conducted to assess compliance with Medicare beneficiary notice requirements, specifically whether the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) was provided to residents.
Findings
The facility failed to provide the SNF ABN notice to 2 of 2 sampled residents reviewed for beneficiary notices. Interviews with facility staff confirmed lack of awareness about the requirement to provide both the Medicare Provider Non-Coverage form and the SNF ABN notice prior to termination of Medicare services.
Deficiencies (1)
Failure to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to Resident #2 and Resident #27.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed and confirmed SNF ABN notice was not provided. |
| Director of Nursing | Director of Nursing | Interviewed and indicated unawareness of requirement to provide both forms. |
| Administrator | Administrator | Interviewed and acknowledged lack of awareness of policy until inspection; committed to compliance going forward. |
Inspection Report
Routine
Deficiencies: 7
Date: Jul 15, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, bed rail safety, pharmaceutical services, dietary services, food safety and sanitation, garbage disposal, and infection prevention and control practices at Arrowhead Healthcare Center, LLC.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during feeding assistance, lack of bed rail safety assessments and physician orders, improper medication storage practices, failure to follow planned dietary menus, unsanitary food preparation and storage conditions, improper garbage disposal, and lapses in infection prevention practices such as inadequate hand hygiene and improper use of disinfectants.
Deficiencies (7)
Failure to ensure residents were treated with dignity and respect during feeding assistance, including staff standing over residents and referring to residents as feeders.
Failure to ensure bed rail safety assessment, physician order, and informed consent for bilateral upper bedrails for one resident.
Failure to ensure two vials of tuberculin were dated when opened and removal of expired vial.
Failure to follow proper planned diet menus for renal and consistent carbohydrate diets for several residents.
Failure to ensure safe and sanitary food preparation and storage practices, including dirty utensils drawer, food debris in microwave, lack of air gap in food prep sink, food debris under equipment, dirty bins, and dirty refrigerators.
Failure to ensure proper disposal of garbage and refuse with uncovered and overflowing containers.
Failure to implement infection prevention and control program, including failure of staff to perform hand hygiene after glove removal, improper use of disinfectant with insufficient wet contact time, unlabeled urinals, and unlabeled peri-wash bottles.
Report Facts
Residents affected: 3
Opened vials of tuberculin: 3
Contact time for disinfectant: 10
Residents affected: 4
Garbage containers: 2
Garbage containers: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 3 | CNA | Named in dignity and respect deficiency for standing over Resident 5 during feeding |
| Assistant Director of Nursing/Quality Assurance | ADON/QA | Interviewed regarding dignity and respect during feeding |
| Director of Nursing | DON | Interviewed regarding dignity, bed rail policy, medication storage, and infection control |
| Licensed Vocational Nurse/Director of Staff Development | LVN/DSD | Interviewed regarding feeding assistance and hand hygiene |
| Licensed Vocational Nurse 1 | LVN | Interviewed regarding feeding assistance and urinal labeling |
| Certified Dietary Manager | CDM | Interviewed regarding dietary menu and kitchen sanitation deficiencies |
| Registered Dietician | RD | Interviewed regarding dietary menu and kitchen sanitation deficiencies |
| Housekeeping Supervisor | HKS | Interviewed regarding cleaning practices and disinfectant use |
| Housekeeper 1 | HK 1 | Observed and interviewed regarding cleaning practices |
| Licensed Vocational Nurse/Infection Preventionist | LVN/IP | Interviewed regarding infection prevention and disinfectant use |
| Certified Nursing Assistant 4 | CNA 4 | Observed and interviewed regarding failure to perform hand hygiene after glove removal |
| Certified Nursing Assistant 1 | CNA 1 | Interviewed regarding feeding Resident 41 |
| Licensed Vocational Nurse 2 | LVN 2 | Interviewed regarding feeding Resident 11 |
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