Cycle 1
Health 2025-06-05 · Fire 2025-06-05
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lake Arrowhead, CA
Mountains Community Hosp DP/SNF
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
29101 Hospital Road, Lake Arrowhead, CA
(909) 336-3651
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
19
Certified beds
Average residents
18
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-06-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.50
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.61
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
3.68
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
6.79
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
3.11
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
6.44
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
1.28
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.38
CMS adjusted RN staffing hours
Adjusted total hours
6.24
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 1.69% |
8.2%
6.5 pts worse
|
Numerator 1 · Denominator 59 |
| Staff flu vaccination coverage | 50% |
42%
8 pts better
|
Numerator 18 · Denominator 36 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
98.5%
8 pts worse
|
93.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 100.0% · 4Q avg 90.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
1.6%
2.5 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
6.8%
5.2 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
4.1%
1.3 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
13.7%
2.7 pts worse
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 15.0% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.0% |
14.2%
5.2 pts better
|
16.7%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.2% |
11.0%
5.2 pts worse
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
10.7%
7.8 pts worse
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
1.2%
2.9 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
10.9%
6.8 pts worse
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
4.7%
3.5 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 1.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-29 · Fire 2024-03-29
0 health deficiencies
No concentrated health issue counts in this cycle.
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-04-20 · Fire 2023-04-20
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-06-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-02
D · Potential for more than minimal harm
2025-06-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-19
D · Potential for more than minimal harm
2025-06-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-19
F · Potential for more than minimal harm
2024-03-29
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-03-29
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-03-29
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-03-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-03-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-03-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-29
F · Potential for more than minimal harm
2024-03-29
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-29
E · Potential for more than minimal harm
2023-04-20
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-20
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-20
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-20
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-20
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-20
K905 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that gas containers are correctly designed and tested, and in locations that are labeled.
Corrected 2023-05-23
D · Potential for more than minimal harm
2023-04-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-05
F · Potential for more than minimal harm
2023-04-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-19
F · Potential for more than minimal harm
2023-04-20
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-20
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-19
Penalties and ownership
What sits behind the stars
Ownership
San Bernardino Mountains Community Hospital District
5% Or Greater Direct Ownership Interest · Organization
Altmeyer, Cheri
Operational/Managerial Control · Individual
Bush, Cynthia
Operational/Managerial Control · Individual
Dahlquist, Gregory
Operational/Managerial Control · Individual
Hernandez, Carmen
Operational/Managerial Control · Individual
Pena, Terry
Corporate Officer · Individual
Turner, Mark
Operational/Managerial Control · Individual
Turner, Mark
Corporate Officer · Individual
Waggener, Yvonne
Operational/Managerial Control · Individual
Waggener, Yvonne
Corporate Officer · Individual
Weiland, Taylor
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Arrowhead Healthcare Center, LLC
San Bernardino, CA
5-star overall rating with 4-star inspections with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Sierra Vista
Highland, CA
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Haven Post Acute
San Bernardino, CA
4-star overall rating with 4-star inspections with $55,737 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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