Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Mountain Home during CMS and state inspections, most recent first.
The facility did not provide or document required abuse and neglect training for staff following a management change, resulting in multiple staff members, including supervisors and non-direct care personnel, lacking up-to-date training as required by facility policy. Both the Administrator and DON confirmed the absence of a current abuse prevention training program and documentation for ongoing staff education.
The facility did not ensure that direct care staff, including CNAs, received required annual training in abuse and neglect prevention. Record reviews showed that several CNAs had not completed this training in over a year, and documentation for recent training was incomplete. The DON confirmed there had been no facility-wide abuse training since new management began, in violation of facility policy.
The facility failed to maintain kitchen cleanliness and proper food safety protocols, including the removal of expired food and adherence to hand hygiene during meal service. Observations revealed dirty kitchen equipment, unlabeled food items, and improper hand hygiene practices by staff.
The facility failed to ensure nurse coverage on the 6:00 PM to 11:59 PM shift on a specific date, as evidenced by the shift report. The Administrator confirmed the deficiency, while the DON and a CNA believed there was enough staff to cover resident care. The Facility Assessment outlined the need for adequate resources, but the lack of nurse coverage indicates a failure to meet these requirements.
A resident with a urinary tract infection did not receive the final dose of a prescribed antibiotic due to an error by an LPN, who incorrectly documented that all doses had been given. The Medical Director and DON confirmed that medications should be administered as ordered unless contraindicated.
The facility failed to dispose of expired medications and supplies and did not store medications and wound treatment supplies safely. Observations revealed expired medical supplies in the medication room and unsecured wound care items in a resident's room. The DON and LPN acknowledged these issues and removed the expired items.
The facility failed to ensure staff performed proper hand hygiene during meal service and medication administration, and failed to don appropriate PPE during resident care. An LPN touched the rim of a water cup while preparing medications, and another LPN entered a resident's room without PPE despite Enhanced Barrier Precautions. Additionally, a CNA handled meal trays without proper hand hygiene.
The facility failed to ensure a certified Infection Control Preventionist (ICP) was employed and available for at least 20 hours a week. The previously certified ICP was terminated, and no certified ICP was currently employed. The DON and Administrator confirmed the deficiency, noting that a night-shift RN was expected to assume the role after completing training.
The facility failed to ensure kitchen equipment was clean and in good working order, affecting 32 residents. Observations included old oil and food particles on shelves, greasy and sticky ovens, and food crumbs on various surfaces. A metal strainer with loose wires posed a choking hazard, and the facility's policy on discarding damaged dishes was not followed.
The facility failed to update the care plan for a resident with scoliosis to include the use of Ankle-foot orthosis (AFO) braces on both lower legs. Despite staff awareness and application of the braces, the care plan was not revised to ensure consistent use and monitoring, leading to a deficiency in care.
Failure to Implement and Monitor Abuse Prevention Training Program
Penalty
Summary
The facility failed to implement and monitor an abuse prevention policy that included a required training program for staff. Record reviews showed that 26 current staff members either lacked documented abuse training or had not received such training since the change in management. Specific staff, including supervisors, aides, and non-direct care personnel, had not had documented abuse or neglect training for several months, with some not trained since before the new management took over. Interviews with the Administrator and Director of Nursing confirmed that no comprehensive abuse or neglect training had been provided to staff since the management change, except for new hires during orientation. The Administrator and DON both acknowledged the absence of a current abuse training program and the lack of documentation for ongoing staff training. A review of facility policies indicated that all staff were required to participate in initial orientation and annual in-service training on topics including abuse, neglect, exploitation, and misappropriation of resident property. However, the facility did not adhere to these requirements, as evidenced by the lack of documented training for both direct and non-direct care staff. The deficiency was further substantiated by the Administrator's and DON's admissions that no abuse or neglect training had been conducted for existing staff since the management transition, and that there was no documentation of such training under current management.
Failure to Provide Annual Abuse/Neglect Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff, including Certified Nursing Assistants (CNAs), received annual training in abuse and neglect prevention, as well as other required in-service education. A review of facility records and transcripts revealed that six current CNAs had not received documented abuse and neglect training since the new management took over. The last recorded training dates for these staff members were over a year prior, and there was no evidence of a facility-wide abuse training since the management change. Additionally, a general orientation document provided by the Director of Nursing (DON) was missing several required staff signatures, further indicating incomplete training documentation. During interviews, the DON confirmed that the only abuse/neglect training provided in the last year was the general orientation, and acknowledged the absence of a comprehensive abuse/neglect training program. The facility's policy requires all staff to participate in initial and annual in-service training on topics including abuse prevention, with proper documentation of completion. However, the lack of recent training and incomplete records demonstrated noncompliance with this policy, potentially affecting all residents in the facility.
Deficiencies in Kitchen Cleanliness and Food Safety
Penalty
Summary
The facility failed to ensure the kitchen and kitchen equipment were maintained in a clean condition and failed to ensure food items were sealed, labeled, and dated. Expired food and supplements were not removed, posing a potential risk for foodborne illness. During an inspection, various expired nutritional drinks were found in the Nurse's Kitchen refrigerator. The Director of Nursing confirmed that expired items should be removed due to potential bacterial growth and degradation of the product. Additionally, the facility's policy on hand hygiene was not adhered to by staff during meal service, as observed with multiple residents being served without proper hand hygiene practices by a Certified Nursing Assistant (CNA). The kitchen was found to be in a state of disrepair and uncleanliness. Observations included old grease and sticky substances on ovens, food crumbs on stoves, and dirty glass doors on cabinets storing seasonings. Several food items were found without labels or dates, including biscuits, potato chips, and various containers of food. The walk-in freezer had a temperature of 43.6 degrees, and a leaking motor was observed, which was dripping fluid into a box of sealed cheese. The dishwasher and other kitchen equipment were also found to be dirty with dried food particles and crumbs. Interviews with staff revealed a lack of adherence to proper food safety and hygiene protocols. The Certified Dietary Manager (CDM) and Food Service Assistant acknowledged the importance of maintaining clean equipment and removing expired food to prevent cross-contamination and potential illness. However, the inspection revealed that these practices were not consistently followed, leading to the deficiencies noted in the report.
Nurse Coverage Deficiency on Evening Shift
Penalty
Summary
The facility failed to ensure nurse coverage on the 6:00 PM to 11:59 PM shift on 11-26-2023, as evidenced by the shift report provided by the Administrator. The report showed no nurse coverage during this time, which had the potential to affect all residents dependent on the nurse for their care. The Administrator confirmed the deficiency, stating there was no way to prove someone worked that shift, although all other dates were adequately covered. The Director of Nursing and a Certified Nursing Assistant both believed there was enough staff to cover resident care, despite the documented deficiency on the specified date. The facility's Social Service provided a Facility Assessment that outlined the need to evaluate the resident population and identify necessary resources to provide competent care. This assessment included details about the resident population, their care requirements, and employee competencies needed to provide the required level of care. However, the lack of nurse coverage on the specified date indicates a failure to meet these outlined requirements, potentially compromising resident care during that shift.
Failure to Administer All Doses of Prescribed Antibiotic
Penalty
Summary
The facility failed to ensure a resident received all doses of a physician-ordered antibiotic. Resident #9, who had a urinary tract infection, was prescribed Doxycycline Monohydrate Oral Tablet 100 mg to be taken twice daily for 7 days, totaling 14 doses. The resident received the first dose on the evening of 05/01/2024 and continued to receive the medication twice daily until 05/07/2024, for a total of 13 doses. However, the final dose was not administered during the morning medication pass on 05/08/2024. LPN #1, who was responsible for the medication administration, incorrectly documented that all doses had been given and later changed the entry to indicate the medication was on hold, which was not accurate. Interviews with LPN #1 revealed that the nurse believed all doses had been administered and thus did not give the final dose. The Medical Director confirmed that medications should be given as ordered unless there is a medical reason to stop, and there was no communication about a missed or delayed dose. The Director of Nurses (DON) also stated that medications should be administered as ordered unless contraindicated, and if a medication is not available, the nurse should check overstock and other sources. The failure to administer the final dose of the antibiotic as ordered constitutes a significant medication error.
Failure to Dispose of Expired Medications and Supplies and Improper Storage
Penalty
Summary
The facility failed to ensure expired medications and supplies were disposed of and did not store medications and wound treatment supplies safely. During an observation, a surveyor found various medical supplies, including a tube of hydrophilic wound dressing, antiseptic cleansing and moisturizing bottles, oral rinse, and an opened bottle of normal saline, sitting on top of a dresser in a resident's room. The resident confirmed that these items belonged to a deceased roommate who was on hospice care. The Licensed Practical Nurse (LPN) acknowledged that these items should not be left in the room and should be stored in the nursing or wound care inventory. The Director of Nursing (DON) confirmed that wound supplies and medications should be securely locked and stored out of residents' reach for their safety and that nurses are responsible for ensuring this. Further observations revealed expired medical supplies in the medication room storage, including sterile isotonic saline, nasopharyngeal swab samples, anti-embolism stockings, and potential hydrogen indicator strips. The DON admitted to being unaware of the expiration dates and removed the expired supplies. Additionally, an LPN found an expired bottle of Melatonin in the medication cart during a medication pass and stated it would be disposed of. These findings indicate a failure to adhere to the facility's policy on medication storage and disposal, posing potential safety risks to residents.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene during meal service and medication administration, as well as failed to don appropriate PPE during resident care. During an observation, an LPN was seen touching the rim of a water cup with their palm and fingers while preparing and administering medications to residents. The LPN acknowledged that this practice should not be done to prevent contamination. Additionally, another LPN entered a resident's room without donning PPE despite the resident being under Enhanced Barrier Precautions due to an indwelling catheter and antibiotic treatment. The LPN only donned gloves after entering the room and touching the resident's bed with their upper legs, which is against the facility's infection control policy. Furthermore, a CNA was observed handling meal trays without proper hand hygiene. The CNA was seen taking off an oven mitt and placing it on top of a cutlery container, then touching plates, scratching their face and nose, and placing hands on their uniform without sanitizing before serving plates to residents. These actions were in direct violation of the facility's hand hygiene policy and had the potential to affect all residents receiving meals and medications in the facility.
Failure to Employ Certified Infection Control Preventionist
Penalty
Summary
The facility failed to ensure that a certified Infection Control Preventionist (ICP) was employed and available for at least 20 hours a week to manage the infection prevention and control program. The facility's policy, dated 10/30/2023, mandates the designation of an ICP to maintain a safe and sanitary environment and prevent the transmission of communicable diseases. However, a review of the training records revealed that the previously certified ICP, an LPN, was terminated a couple of weeks prior to the survey, and no certified ICP was currently employed at the facility. An LPN confirmed the absence of a certified ICP and mentioned that a new hire, who was not yet certified, was expected to take over the role but had not completed the necessary training yet. Interviews with the Director of Nursing (DON) and the Administrator further confirmed the deficiency. The DON acknowledged the importance of having an ICP to prevent and contain infections and identify them promptly. The Administrator stated that the facility was required to have an ICP according to CMS and facility standards. The Administrator also mentioned that the DON had been handling the ICP responsibilities until two weeks ago, and a night-shift RN was slated to assume the role after completing the required training. However, at the time of the survey, the facility lacked a certified ICP, thereby failing to comply with the infection prevention and control program requirements.
Facility Failed to Maintain Clean and Functional Kitchen Equipment
Penalty
Summary
The facility failed to ensure that kitchen equipment was clean and in good working order, which had the potential to affect 32 residents receiving meals from the facility's kitchen. Observations included a rolling storage shelf with stock pots full of old oil and food particles, a double door handled oven covered in old grease and sticky substances, and a stove with a greasy pot and food crumbs. Additionally, metal tables stored metal dishes with grease and dust, and a rolling warming plate container and trays had food crumbs and dried substances. A steam table also had food crumbs on top and underneath. Further issues were identified with the use of a metal strainer with loose wires, which the Certified Dietary Manager (CDM) acknowledged could pose a risk of metal getting into the food and causing choking hazards. The CDM and a dietary employee confirmed that equipment is checked daily when used, but the presence of broken and frayed equipment indicated lapses in this practice. The facility's policy on General Sanitation-Food and Nutrition stated that chipped, corroded, and cracked dishes should be discarded, but this was not adhered to, as evidenced by the observations made by the surveyor.
Failure to Update Care Plan for Use of AFO Braces
Penalty
Summary
The facility failed to revise the care plan for Resident #25 to include the use of Ankle-foot orthosis (AFO) braces on both lower legs, which are necessary to prevent a decline in Range of Motion. Despite the presence of a facility policy that mandates individualized, person-centered, comprehensive care plans, the care plan for Resident #25 did not reflect the need for AFO braces. Interviews with staff, including a CNA, LPN, and the Director of Nursing (DON), revealed that while the staff were aware of the need for the braces and their application, the care plan was not updated to include this critical information. The CNA and LPN both indicated that the braces were part of the care plan, but the DON and Social Services worker confirmed that the care plan had not been updated to reflect the new orders or changes in the resident's condition. Resident #25, who has a medical diagnosis of scoliosis, was observed by the surveyor wearing braces on both lower legs. The CNA and LPN described the process of applying and removing the braces and monitoring the resident's skin for any signs of breakdown or irritation. However, the DON admitted to not being present during these procedures and assumed that the tasks were being carried out by the nursing staff. The Social Services worker indicated that care plans are updated when there is a change in the resident's condition or new orders, but this had not been done for Resident #25. This oversight in updating the care plan led to a failure in ensuring consistent use of the braces, which is essential for maintaining the resident's Range of Motion and preventing further decline.
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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 Mountain Home
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hiram Shaddox Health And Rehab | 2.6 mi | ★★★★★ | 0 | 0 |
| Care Manor Nursing And Rehab | 3.1 mi | ★★★★★ | 5 | 0 |
| Gassville Therapy And Living | 8.5 mi | ★★★★★ | 4 | 0 |
| Twin Lakes Therapy And Living | 14.6 mi | ★★★★★ | 0 | 0 |
| Gainesville Nursing | 18.2 mi | ★★★★★ | 2 | 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 July 2026) and official state health department websites.