Nursing Care Index

Arrowhead Springs Healthcare

San Bernardino, San Bernardino County, California · CCN 055708 · For-profit (Corporation) · part of The Ensign Group (342 facilities, chain average 3.2 stars)

CMS rates Arrowhead Springs Healthcare 4 of 5 overall as of August 2026. 119 certified beds, 109 residents a day on average. 30 citations on record from the current inspection cycles; no fines on record.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★★★★☆ 4 of 5
Health inspections★★★★☆ 4 of 5
Staffing★★★★☆ 4 of 5
Quality measures★★★★☆ 4 of 5
Quality: long-stay / short-stay5 / 3 of 5

Staffing

Total nurse staffing4.61138 hours per resident per day
Registered nurses0.31556 hours per resident per day
Weekend total3.88453 hours per resident per day
Nursing staff turnover25.2% (registered nurses 22.2%)
Administrators who left1

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-06-04 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies · tag F0582
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-06-25
2026-06-04 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · tag F0644
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-06-25
2026-06-04 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies · tag F0693
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-06-25
2026-06-04 Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · tag F0554
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-25
2026-06-04 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies · tag F0636
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-25
2026-06-04 PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · tag F0645
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-25
2026-06-04 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-25
2026-06-04 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies · tag F0761
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-25
2026-06-04 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-06-25
2025-04-24
complaint survey
Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies · tag F0814
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-05-16
2025-04-24
complaint survey
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · tag F0584
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-16
2025-04-24
complaint survey
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-16
2025-04-24
complaint survey
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · tag F0677
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-16
2025-04-24
complaint survey
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Quality of Life and Care Deficiencies · tag F0700
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-16
2025-04-24
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-05-16
2025-03-07
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-17
2025-02-12
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-02-24
2024-11-06
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-11-15
2024-05-24
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-06-06
2023-09-01
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-31
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-09-14
2022-05-26 Keep all essential equipment working safely.
Environmental Deficiencies · tag F0908
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2022-06-22
2022-05-26 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies · tag F0578
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-06-22
2022-05-26 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies · tag F0688
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-06-22
2022-05-26 Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · tag F0692
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-06-22
2022-05-26 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies · tag F0693
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-06-22
2022-05-26 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-06-22
2022-05-26 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · tag F0756
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-06-22
2022-05-26 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-06-22
2022-05-26 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-06-22

Fines and payment denials

No fines or payment denials on record since 2023.

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Alvarado Health Holdings LLC
Organization
adp of the snf2022-01-01
Ensign Services Inc.
Organization
adp of the snf2022-02-01
Standard Bearer Healthcare Op, Lp
Organization
adp of the snf2022-01-01
The Ensign Group Inc.
Organization
adp of the snf2022-01-01
Mangoba, Luther
Individual
adp of the snf2022-02-01
Sanchez Gonzalez, Yamaliel
Individual
adp of the snf2022-02-01
Burnam, Soon
Individual
corporate officer2022-02-01
Keetch, Chad
Individual
corporate officer2014-01-01
Port, Barry
Individual
corporate officer2019-01-01
Willits, Adam
Individual
corporate officer2021-03-29
Burnam, Soon
Individual
managing control - governing body2022-02-01
Mangoba, Luther
Individual
operational/managerial control2022-02-01
Sanchez Gonzalez, Yamaliel
Individual
operational/managerial control2022-02-01

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in San Bernardino County.