Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Mountains Community Hosp DP/SNF
Lake Arrowhead, CA · 19 certified beds · Last Life Safety survey June 5, 2025
CMS Certification Number 555467 · first certified June 1991
Ownership
Independently operated (no chain recorded by CMS) · Government - Hospital district
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CA
28 citations — more than 79% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 11.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: June 2026 to November 2026. This facility’s last Life Safety survey was June 2025. Facilities in CA are typically surveyed 12–18 months after the last one (median 14), measured over 1,766 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
7 of the 28 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 28 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 28 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 20, 2023 | 12 |
| March 29, 2024 | 11 |
| June 5, 2025 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-06-05 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2024-03-29 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2025-06-05 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-03-29 |
| K-0161 | Use approved construction type or materials. | 2 | 2025-06-05 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-03-29 |
| E-0035 | Provide family notifications of emergency plan. | 1 | 2024-03-29 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-03-29 |
What the citations cover
- Smoke Deficiencies 13
- Emergency Preparedness Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Construction Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Emergency Preparedness Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Construction Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 5, 2025 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (June 18, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 18, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 2, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 19, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 19, 2025) |
March 29, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (April 29, 2024) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (April 29, 2024) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (April 29, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 29, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 29, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 29, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (April 29, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 29, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (April 29, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (April 29, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 29, 2024) |
April 20, 2023 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (May 23, 2023) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (May 23, 2023) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (May 23, 2023) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (May 23, 2023) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (May 23, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 23, 2023) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (May 23, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 23, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 23, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (May 23, 2023) |
| K-0905 | Ensure that gas containers are correctly designed and tested, and in locations that are labeled. | Deficient, Provider has date of correction (May 23, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 23, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.