5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lake Arrowhead, CA
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
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
Staffing
RN hours / resident day
1.50
Registered nurse staffing
LPN hours / resident day
1.61
Licensed practical nurse staffing
Aide hours / resident day
3.68
Nurse aide staffing
Weekend hours
6.44
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
No concentrated health issue counts in this cycle.
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-18
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-02
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-19
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-19
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-04-29
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-04-29
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-04-29
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-29
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-29
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
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
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-29
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-29
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-29
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-05-23
Fire Safety
Provide emergency officials' contact information.
Corrected 2023-05-23
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-23
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-05-23
Fire Safety
Use approved construction type or materials.
Corrected 2023-05-23
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-23
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-05-23
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-23
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-23
Fire Safety
Ensure that gas containers are correctly designed and tested, and in locations that are labeled.
Corrected 2023-05-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-23
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-05
Health
Assess the resident when there is a significant change in condition
Corrected 2025-07-05
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-05
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
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-05
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
Health
Dispose of garbage and refuse properly.
Corrected 2023-05-19
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-05-19
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-19
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-19
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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