Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountains Community Hosp Dp/snf during CMS and state inspections, most recent first.
Surveyors found expired IV catheters and extension sets in the procedure cart and supply room during an observation with the DSD and an LVN. Both staff confirmed the supplies were expired and should have been discarded. The CNO acknowledged that the facility's infection control policy requires regular checks and removal of expired items, which was not followed in this instance.
A resident with multiple chronic conditions experienced a significant decline, including new right arm immobility and very weak speech, but the facility did not complete a required MDS assessment within 14 days as per policy. The most recent MDS inaccurately reflected the resident's status, and staff confirmed the assessment was not updated despite the ongoing change in condition.
A resident with multiple chronic conditions experienced new right-sided weakness and speech impairment, but these changes were not reflected in the MDS assessment. Despite documentation and staff awareness of the decline, the required change of condition assessment was not completed, resulting in inaccurate resident records.
A resident with multiple chronic conditions experienced a decline in speech and mobility, but staff did not update the care plan to reflect these changes. The MDS assessment remained inaccurate, and the care plan was not revised as required by facility policy, despite staff being aware of the resident's decline and available prompts in the EHR system.
A resident with multiple chronic conditions did not receive a prescribed dose of furosemide when an LVN withheld the medication based on a low systolic blood pressure, despite the current order lacking hold parameters. The omission occurred because the renewed order in the E-MAR did not include the previous hold instructions, resulting in a medication error as confirmed by facility policy and leadership.
Expired Medical Supplies Found in Procedure Cart and Supply Room
Penalty
Summary
During an observation and interview conducted in the facility's treatment cart and medical supply room, surveyors, accompanied by the Director of Staff Development and an LVN, found expired medical supplies that were readily available for use. Specifically, 41 safety intravenous (IV) catheters and nine IV extension sets were identified as being past their expiration dates by three and four days, respectively. Both staff members present confirmed that these items were expired and acknowledged that they should have been discarded. A subsequent interview and review of the facility's Infection Prevention and Control policy with the Chief Nursing Officer revealed that the facility's procedures require regular checks of medical supplies and the removal of expired items. The CNO confirmed that the expired supplies had not been removed as required by policy, and acknowledged that this failure was not in accordance with the facility's infection prevention and control procedures.
Failure to Complete Timely MDS Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to complete a significant change in status assessment (MDS) within 14 days for a resident who experienced a notable decline in condition. The resident, who had a history of diabetes, hypertension, chronic kidney disease, and a right tibial fracture, was observed to have developed new symptoms including inability to lift the right arm and very weak speech, with difficulty completing sentences. Despite these changes, the most recent MDS quarterly assessment inaccurately documented the resident as having clear speech, no upper extremity impairment, and no neurological diagnosis such as aphasia. The LVN/DSD confirmed that the assessment did not reflect the resident's current status and that the change in condition had persisted for over a month without the required MDS update. Interviews with facility leadership and review of the facility's policy revealed that the policy required a significant change in status assessment MDS to be generated within 14 days of a change in condition. The CNO acknowledged that this policy was not followed. Progress notes from the physician also documented the resident's inability to move the right arm and very weak voice, further confirming the change in condition that was not properly assessed or documented in accordance with both facility policy and federal requirements.
Inaccurate MDS Assessment Following Resident's Decline
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was completed accurately, resulting in the omission of significant changes in the resident's condition. The resident, who had a history of diabetes, hypertension, chronic kidney disease, and a right tibial fracture, was observed to have new functional limitations in the right upper extremity and speech impairments. Despite these changes, the MDS quarterly assessment did not reflect the resident's inability to lift her right arm, her speech difficulties, or the presence of neurological issues such as aphasia. Multiple records, including progress notes, a speech language pathologist evaluation, and an interdisciplinary care conference, documented the resident's decline, but these were not incorporated into the MDS assessment. Interviews with facility staff, including the LVN/Director of Staff Development and the Chief Nursing Officer, confirmed that the MDS assessment was inaccurate and that no change of condition assessment had been initiated, even though the resident's decline had persisted for over 14 days. The facility's policy required a significant change in status assessment MDS to be generated within 14 days of a change in condition, but this was not done. As a result, the resident's assessment did not accurately represent her current status, as verified by staff and documentation.
Failure to Update Care Plan After Resident's Change in Condition
Penalty
Summary
Facility staff failed to update a comprehensive care plan for a resident following a significant change in condition. The resident, who had a history of diabetes, hypertension, chronic kidney disease, and a right tibial fracture, was observed to have new deficits including difficulty speaking, inability to complete sentences, and inability to lift her right arm. Despite these changes, the resident's Minimum Data Set (MDS) quarterly assessment did not reflect the new impairments, and no change of condition was documented. The Licensed Vocational Nurse/Director of Staff Development confirmed that the MDS was inaccurate and that the resident had shown a decline for about a month without an updated care plan. Further review revealed that the care plan had not been revised since before the resident's decline, and the facility's policy requiring care plan updates after a change of condition was not followed. Interviews with staff indicated that there were mechanisms in place to prompt care plan updates, such as notifications in the electronic health record when new therapies were added, but these were not utilized. The Chief Nursing Officer acknowledged that the care plan was not reviewed or updated after the resident's change in status, confirming non-compliance with facility policy.
Medication Error Due to Omission of Hold Parameters in Furosemide Order
Penalty
Summary
A deficiency occurred when a resident with a history of benign prostatic hyperplasia, hypothyroidism, and cerebral palsy was not administered their prescribed furosemide medication as ordered. During a medication pass, an LVN held the resident's furosemide dose based on a systolic blood pressure reading of less than 100, despite the current medication order lacking any hold parameters. The LVN referenced a previous order that included such parameters, but the renewed order did not specify them, leading to the medication being withheld without proper authorization. Record review and interviews confirmed that the medication order for furosemide, renewed in the electronic medical administration record (E-MAR), did not include instructions to hold the medication for low blood pressure. The facility's policy requires all medications to be administered as prescribed and properly documented, and deviations such as this are considered medication errors. The Chief Nursing Officer acknowledged that this was a system error related to the communication and entry of the renewed order into the E-MAR.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lake Arrowhead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arrowhead Healthcare Center, Llc | 9.7 mi | ★★★★★ | 0 | 0 |
| Sierra Vista | 9.7 mi | ★★★★★ | 18 | 0 |
| Haven Post Acute | 10.1 mi | ★★★★★ | 1 | 0 |
| Hillcrest Nursing Home | 10.2 mi | ★★★★★ | 6 | 0 |
| Del Rosa Villa | 10.2 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.