Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Forest Senior Living At Hot Springs Village during CMS and state inspections, most recent first.
Missing Written Transfer and Bed-Hold Notices: The facility failed to provide complete written transfer and bed-hold notices for two residents sent to the hospital. One resident was cognitively intact and had heart disease and acute respiratory failure; the other had moderate cognitive impairment with ESRD, respiratory failure, and brain dysfunction. Records showed only progress notes or partial contact attempts with family/POA, and the facility’s form lacked required appeal rights information, including how to request and submit an appeal.
The facility did not ensure EBP and proper PPE were used during PEG tube care and PICC IV antibiotic administration for two residents. An LPN performed PEG tube care with gloves only and no gown, and another LPN administered IV antibiotics through a PICC with gloves only and no gown. The IP and DON stated gowns and gloves were required for these high-contact care activities, and one resident’s EBP door sign was missing at the time of observation.
A resident with a full code status became unresponsive, but facility staff failed to initiate CPR despite the resident's advanced directive. The resident, with a history of heart and respiratory issues, experienced two episodes of unresponsiveness. Staff, including CNAs and LPNs, did not perform CPR, citing physical limitations. EMS arrived and initiated CPR, but the resident was pronounced expired at the hospital. The facility's policy required immediate CPR initiation, which was not followed, resulting in a deficiency related to quality of life.
The facility failed to maintain proper sanitation and food safety standards, with observations of dirty equipment, improperly stored items, and lack of adherence to cleaning schedules. Issues included broken floor drain grates, grimy substances, uncovered food items, and improperly stored chemicals. Additionally, open food items and spices lacked dates, and some were expired, posing contamination risks.
A facility failed to secure a resident's electronic medical record (EMR) by leaving a laptop unattended in a hallway, exposing the resident's private health information to guests and family members. Staff interviews confirmed that the screen should have been locked to protect confidentiality, but this protocol was not followed.
The facility failed to securely store harmful chemicals, razors, and nail trimmers, posing a safety risk to residents. Surveyors found unsecured germicidal wipes in a resident's room and common areas, and unlocked cabinets with cleaning chemicals and personal care items in bathrooms. Staff confirmed these items should be locked to prevent resident access, especially for those on blood thinners. The facility lacked a policy for chemical storage, contributing to the unsafe environment.
An LPN failed to perform proper hand hygiene during the care of a resident with a feeding tube. The LPN removed gloves to retie the resident's gown without performing hand hygiene before applying a new pair of gloves, contrary to the facility's infection control policy. The resident had a history of hemiplegia and required tube feedings. Both the LPN and the DON confirmed the breach in protocol.
A facility failed to implement physician's orders for wound care and identify new skin changes for a resident with severe cognitive impairment. Despite policies requiring timely treatment of skin tears, the resident's treatment record showed no wound care orders or documentation, and dressings were observed without corresponding orders. Nursing staff confirmed the lack of observation during assessments, and the DON acknowledged the absence of physician's orders and follow-up on treatments, resulting in a deficiency in care.
Missing Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written notification to the resident and/or the resident’s representative when two residents were transferred to the hospital, and the documentation reviewed did not include the required transfer and bed-hold information. Resident #45’s record showed a BIMS score of 15, indicating cognitive intactness, and diagnoses that included heart disease and acute respiratory failure with decreased oxygen to tissues and organs. When Resident #45 was sent to the ER for worsening pulmonary edema, the only document provided was a nursing progress note stating the resident’s wife was present and notified; it did not contain a complete notice of transfer or bed hold. Resident #7’s record showed a BIMS score of 10, indicating moderate cognitive impairment, with diagnoses including end stage kidney disease, respiratory failure, and brain dysfunction. The record reflected two hospitalizations, but the facility could not produce a notice of bed hold or notice of transfer for either transfer. The only documents provided were progress notes showing that staff contacted the POA or family about whether they wanted to hold the bed, that one attempt to reach family was unsuccessful, and that family later said they wanted to hold the resident’s bed. Interviews with the DON, Administrator, LPN, and Admissions Coordinator showed staff understood nurses or social services were involved in bed-hold and transfer notifications, but the facility did not have evidence that complete written notices were given. The facility’s policy required written notice of transfer or discharge including the reason, effective date, location, and appeal rights, as well as written bed-hold information at the time of transfer or within 24 hours for an emergency transfer. The form attached to the facility’s materials did not include the resident’s appeal rights information, including the name, address, email, telephone number of the appeal entity, or instructions for obtaining and submitting an appeal request.
Failure to Implement EBP and Proper PPE During PEG Tube and PICC Care
Penalty
Summary
The facility did not ensure Enhanced Barrier Precautions (EBP) were implemented and did not ensure staff donned proper PPE during PEG tube care and IV medication administration for two residents. One resident had severe cognitive impairment, a stroke history, memory and behavior problems, loss of feeling to one side of the body, and a surgical opening to the stomach for feeding tube nutrition. That resident’s care plan and physician order indicated EBP were required because of the PEG tube. During observation, an LPN performed PEG placement check and tube flush while wearing gloves but no gown, and the LPN brushed against the resident’s bed and body during the procedure. The LPN stated she was not aware of any EBP for PEG tube care, even though signage on the door indicated the resident was on EBP. The IP and DON later stated that gloves and gowns were to be worn for PEG tube care, including flushes, and that staff had been in serviced on proper PPE. A second resident was admitted with diagnoses including infection and inflammatory reaction due to an internal artificial left knee, UTI, and diabetes mellitus, and was ordered IV antibiotics through a PICC line while on EBP. During observation, an LPN prepared and administered IV antibiotics through the PICC while wearing gloves only and no gown; the room door did not have an EBP sign at that time. The LPN stated she believed a gown and gloves were needed for urinary tract care but only gloves were needed for PICC care. The IP and DON stated that a gown and gloves should be worn when accessing the PICC for antibiotic administration, and the DON stated the EBP sign had been placed on the door initially but had to be replaced because it was no longer there.
Failure to Initiate CPR for Resident with Full Code Status
Penalty
Summary
The facility failed to adhere to a resident's request for resuscitative measures, resulting in a deficiency related to the quality of life. The incident involved a resident with a full code status who became unresponsive in their room. Despite the resident's advanced directive indicating a wish to be resuscitated, the facility staff did not initiate CPR. Emergency Medical Services (EMS) arrived and performed CPR, but the resident was pronounced expired at the hospital. The resident had a medical history of coronary artery disease, heart failure, chronic obstructive pulmonary disease, hypertension, and acute respiratory failure. On the evening of the incident, the resident experienced two episodes of unresponsiveness. During the first episode, the resident became responsive after a short period, but during the second episode, the resident remained unresponsive. Despite the presence of staff, including two CNAs and two LPNs, CPR was not initiated. The staff cited the resident's size and their own physical limitations as reasons for not moving the resident to the floor to begin CPR. Interviews with staff revealed a lack of action in initiating resuscitative measures. The LPNs confirmed that they did not attempt to assist the resident to the floor for CPR, and the paramedic who arrived on the scene noted that no resuscitative measures were being attempted by the staff. The facility's policy required immediate initiation of CPR by a licensed staff member trained in CPR, but this was not followed. The deficiency was identified as an Immediate Jeopardy situation, indicating a serious risk to resident safety.
Removal Plan
- The facility will initiate education training of all staff on code blue.
- The facility will initiate education training of all nurses on physician notification and CPR.
- The facility will have a code blue drill on every shift.
Sanitation and Food Safety Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the kitchen and food storage areas. Observations revealed broken and dirty floor drain grates, grimy substances under the ice machine, and boxes stored directly on the floor in the cleaning closet. The dry goods storage room had stains, debris, and improperly stored items, while the walk-in freezer and refrigerator had buildup of unknown substances. Equipment such as a three-tiered cart and a sandwich refrigerator cart were found with grime and stagnant liquid, posing risks of cross-contamination. Further inspection showed that the can opener blade was dirty, and food preparation areas had uncovered items and improperly stored lemon juice. The dishwasher room had dish racks on the floor and buildup on the floor and equipment surfaces. Chemicals were improperly stored near food items, and the facility's cleaning schedule and chemical storage policies were not adhered to, leading to potential contamination risks. Additionally, the facility failed to date open food items and spices, with some items being expired. The walk-in refrigerator door did not seal properly, and several food items lacked expiration dates. The dry goods storage area contained dented cans and expired items, increasing the risk of foodborne illnesses. These deficiencies highlight significant lapses in food safety and sanitation practices within the facility.
Unauthorized Exposure of Resident's EMR
Penalty
Summary
The facility failed to secure residents' private health information on facility computers, leading to unauthorized exposure of electronic medical records (EMR). During an observation, a surveyor noted a facility laptop left unattended on a snack cart in the hallway, with the screen facing outward. This allowed multiple guests and family members in the hallway to view the electronic health record of a resident, including their name, supplement order details, and scheduling information. The laptop remained unattended and visible for an extended period, from 4:21 PM to 4:48 PM, before a Licensed Practical Nurse (LPN) returned to the cart. Interviews conducted with facility staff confirmed the deficiency. An LPN stated that the screen should be locked within the electronic health record system before leaving it unattended to protect residents' privacy and confidentiality. The Director of Nursing (DON) also confirmed that the facility's procedure requires locking the laptop screen to safeguard the confidentiality of residents' electronic medical records. Despite these established protocols, the failure to secure the laptop screen resulted in a breach of privacy for the resident involved.
Failure to Secure Hazardous Items in Resident Areas
Penalty
Summary
The facility failed to ensure the secure storage of harmful chemicals, nail trimmers, and razors, which posed a safety risk to residents. During observations, surveyors found unsecured containers of germicidal wipes in Resident #135's room and in common areas. Additionally, the bathroom on the 300 Hall and the bathing/spa room on the 100 Hall had unlocked cabinets containing various cleaning chemicals, a disposable razor, and nail trimmers. These items were accessible to residents, including Resident #135, who had medical conditions such as unsteadiness on feet and difficulty walking. Interviews with facility staff, including an LPN and the DON, confirmed that chemicals, razors, and nail trimmers should be stored securely to prevent resident access. The LPN acknowledged that residents could misuse germicidal wipes or injure themselves with razors and nail trimmers, especially if they were on blood thinners. The DON also confirmed that these items should be locked away to prevent potential harm to residents. The facility lacked a policy for chemical storage and hazards, as stated by the Administrator. Safety data sheets for the chemicals found indicated that they were intended for professional use and could cause harm if not handled properly. The unsecured storage of these items in resident-accessible areas demonstrated a failure to maintain a safe environment, as required by regulations.
Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during the care of a resident with a feeding tube. According to the facility's hand hygiene policy, hand hygiene should be performed after glove removal and before applying a new pair of gloves. However, during an observation, an LPN was seen checking the residual of a PEG tube and then removing her gloves to retie the resident's gown without performing hand hygiene. She then applied a new pair of gloves and continued with the task, which was a breach of the facility's infection control practices. The resident involved had a history of hemiplegia and hemiparesis following a cerebral infarction, dysphagia, and required tube feedings. The resident's care plan included specific instructions for tube feeding, which the LPN was following at the time of the observation. During interviews, both the LPN and the Director of Nursing confirmed that hand hygiene should have been performed after glove removal and before applying a new pair of gloves to prevent cross-contamination and the transmission of bacteria.
Failure to Implement Physician's Orders for Wound Care
Penalty
Summary
The facility failed to implement and carry out physician's orders for wound care and to identify new skin changes for a resident reviewed for skin conditions. The facility's policy on skin tear treatment and prevention required that skin tears be treated within 12 hours to promote early wound healing and prevent further skin damage or infection. However, the resident's treatment record for June 2024 showed no wound care orders or documentation of completed wound care, despite the presence of dressings on the resident's arms observed by the surveyor. The resident, who was admitted with diagnoses including lack of coordination and severe cognitive impairment, had a care plan indicating a potential for pressure ulcer development. Despite this, there was no documentation of skin checks in the resident's electronic health record for the past 30 days. Observations by the surveyor revealed dressings on the resident's arms with no corresponding physician's orders or documentation in the medical record. Interviews with nursing staff confirmed that the dressings were not observed during weekly skin assessments, and no orders for skin care dressings were found in the resident's chart. The Director of Nursing confirmed that there were no physician's orders for wound care in the resident's chart and acknowledged that the charted treatment on June 1, 2024, was completed without a physician's order. Additionally, the facility's standing orders for wound care were not followed, as there was no follow-up on the initial treatment, and other skin conditions on the resident's right arm were not identified or addressed. The facility's failure to adhere to its policies and procedures for wound care and skin assessments resulted in a deficiency in providing appropriate treatment and care according to orders and the resident's needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hot Springs Village
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Blossoms At The Village Rehab & Nursing Center | 6.6 mi | ★★★★★ | 4 | 0 |
| Belvedere Nursing And Rehabilitation Center, Llc | 9.6 mi | ★★★★★ | 1 | 0 |
| The Springs Of Park Ave | 11 mi | ★★★★★ | 0 | 0 |
| The Blossoms At Hot Springs Rehab And Nursing Cent | 15.2 mi | ★★★★★ | 0 | 0 |
| The Pines Nursing And Rehabilitation Center | 15.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lake Forest Senior Living At Hot Springs Village.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.