Arrowhead Springs Healthcare

Name: Arrowhead Springs Healthcare
Address: 1335 N. Waterman Ave., San Bernardino, CA, 92404, US
Telephone: 9098850268

1335 N. Waterman Ave., San Bernardino, CA 92404 · San Bernardino County · 119 certified beds · avg 109 residents/day · certified since Jan 1, 1971

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.73

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (30)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 4, 2026	E · Potential for harm, repeated	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Jun 4, 2026	E · Potential for harm, repeated	The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
Jun 4, 2026	E · Potential for harm, repeated	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Jun 4, 2026	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Jun 4, 2026	D · Potential for harm, one-off	The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
Jun 4, 2026	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Jun 4, 2026	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jun 4, 2026	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jun 4, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Apr 24, 2025	F · Potential for harm, facility-wide	The facility did not dispose of garbage and refuse properly. · from a complaint
Apr 24, 2025	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Apr 24, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Apr 24, 2025	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Apr 24, 2025	D · Potential for harm, one-off	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint
Apr 24, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Mar 7, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Feb 12, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Nov 6, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 24, 2024	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Sep 1, 2023	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Aug 31, 2023	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
May 26, 2022	F · Potential for harm, facility-wide	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
May 26, 2022	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
May 26, 2022	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
May 26, 2022	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
May 26, 2022	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
May 26, 2022	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 26, 2022	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
May 26, 2022	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
May 26, 2022	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (6 → 9).

Year	Citations	Worst severity that year
2022	9	F
2023	2	E
2024	2	D
2025	8	F
2026	9	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.73	4.31	3.95	top 20% in California; top 18% in the U.S.
Registered Nurse hours	0.32	0.61	0.69	bottom 16% in California; bottom 12% in the U.S.
Weekend total nurse staffing	3.99	3.90	3.50	top 34% in California; top 23% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.21	0.51	0.48	bottom 12% in California; bottom 13% in the U.S.
Total nursing staff turnover (%)	25.2	36.7	45.8	top 17% in California; top 7% in the U.S.
RN turnover (%)	22.2	38.1	42.9	top 23% in California; top 17% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.61, RN 0.32, weekend 3.88. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Alvarado Health Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	01/01/2022
Burnam, Soon	Individual	Managing Control - Governing Body	NOT APPLICABLE	02/01/2022
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	02/01/2022
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	02/01/2022
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	01/01/2014
Mangoba, Luther	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2022
Mangoba, Luther	Individual	ADP of the SNF	NOT APPLICABLE	02/01/2022
Port, Barry	Individual	Corporate Officer	NOT APPLICABLE	01/01/2019
Sanchez Gonzalez, Yamaliel	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2022
Sanchez Gonzalez, Yamaliel	Individual	ADP of the SNF	NOT APPLICABLE	02/01/2022
Standard Bearer Healthcare Op, LP	Organization	ADP of the SNF	NOT APPLICABLE	01/01/2022
The Ensign Group INC	Organization	ADP of the SNF	NOT APPLICABLE	01/01/2022
Willits, Adam	Individual	Corporate Officer	NOT APPLICABLE	03/29/2021

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
"How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
"How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
"If my family member is able to manage their own medications, would you allow it, and how is that decided?"
"How soon after admission is a full assessment completed, and how are the findings shared with the family?"
"How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Medical Center Convalescent Hospital	0.2 mi	San Bernardino, CA	★★★★☆	4/5
Valley Healthcare Center	0.4 mi	San Bernardino, CA	★★★★☆	3/5
Waterman Canyon Post Acute	0.5 mi	San Bernardino, CA	★★★★☆	4/5
Haven Post Acute	1.6 mi	San Bernardino, CA	★★★★☆	4/5
Del Rosa Villa	1.9 mi	San Bernardino, CA	★★☆☆☆	2/5	abuse
Community Convalescent Center of San Bernardino	2.3 mi	San Bernardino, CA	★★★★★	5/5
Community Hospital of San Bernardino DP SNF	2.3 mi	San Bernardino, CA	★★☆☆☆	3/5
Sierra Vista	3.0 mi	Highland, CA	★★★☆☆	2/5	abuse
Arrowhead Healthcare Center, LLC	3.1 mi	San Bernardino, CA	★★★★☆	4/5
Shandin Hills Behavior Therapy Center	3.7 mi	San Bernardino, CA	★★★★★	5/5
Hillcrest Nursing Home	3.9 mi	San Bernardino, CA	★★★★★	5/5
Highland Palms Healthcare Center	4.0 mi	Highland, CA	★★★★☆	4/5

Compare this facility with the 3 closest →

All facilities in San Bernardino →

Facility data as of CMS processing date 2026-08-01. CCN 055708.

The Care File

Visit checklist — Arrowhead Springs Healthcare

1335 N. Waterman Ave., San Bernardino, CA 92404 · 9098850268

Health inspection rating 4/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
☐ "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
☐ "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
☐ "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
☐ "How soon after admission is a full assessment completed, and how are the findings shared with the family?"
☐ "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 055708 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)