Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Place during CMS and state inspections, most recent first.
A resident with Parkinsonism, dementia, and oropharyngeal dysphagia had documented swallow guidelines and speech therapy recommendations requiring upright positioning, small bites, slow rate, alternating food and liquids, no talking while eating, and close supervision with staff maintaining continuous visual monitoring and cueing. During a meal, the resident was seated at a table with other residents, self-feeding pureed food, while a restorative CNA and an RN supervisor were focused on assisting other residents and did not keep eyes on him. Staff later reported they did not know if he was alternating bites with liquids or eating too fast when he began choking, became red in the face, and appeared unable to cough, requiring abdominal thrusts by the RN supervisor. Interviews and records confirmed the resident was known to eat quickly and take large spoonfuls, and that close supervision as ordered was not maintained at the time of the choking episode.
A resident with a documented history of falls and falling out of bed had a care plan intervention for use of a floor mattress. During observation, the resident was in bed without the floor mattress in place; instead, it was propped against the wall and no staff or caregivers were present in the room. A CNA later confirmed that floor mattresses are supposed to be placed on the floor next to the bed when the resident is in bed, indicating the fall-prevention intervention was not implemented as care-planned.
A narcotic pain medication delivered for a resident was not properly signed in or secured by nursing staff, resulting in the medication being left unattended and ultimately going missing. The medication was not stored in the required double-locked compartment, and facility procedures for handling controlled substances were not followed.
The facility failed to provide safe resident transfers and incontinence care, resulting in falls and injuries. A resident with impaired cognition and vision fell during incontinence care due to inadequate staff assistance, sustaining a femur fracture. Another resident, requiring two-person assistance, was improperly transferred by a single CNA, leading to a fall. The incidents highlight communication failures regarding care requirements.
The facility failed to prevent cross-contamination in dishwashing and thickener storage. A dishwasher moved between dirty and clean dishes without washing hands, violating hand hygiene policy. Additionally, a cook improperly stored measuring cups in a thickener container, risking contamination. The Director of Dining Services confirmed these practices were against facility policies.
A resident with severe cognitive impairment and multiple diagnoses, including Parkinson's disease and dysphagia, had a gastrostomy tube for nutrition. A registered nurse administered enteral feeding without verifying the tube's placement, as required by the facility's protocol. The nurse admitted to not checking the placement due to the absence of her stethoscope. The Director of Nurses confirmed the necessity of checking tube placement to prevent potential complications, as outlined in the facility's Enteral Nutrition policy.
A facility failed to ensure proper PPE use for a resident with a urinary catheter. A CNA assisted the resident with transfers and toileting without wearing a gown, despite signage indicating the need for enhanced barrier precautions. The facility's policy requires gowns and gloves for high-contact care activities to prevent cross-contamination.
A resident with severe cognitive impairment was found in the dining room wearing only a hospital gown, despite having appropriate clothing available. The resident's daughter complained about the lack of grooming and inappropriate attire. The facility's staff acknowledged the incident, which was against their policy of maintaining resident dignity and privacy.
A facility failed to maintain a homelike environment by allowing a damaged nightstand to remain in a resident's room. Despite frequent staff presence, the nightstand, with a hanging handle and missing section, was not repaired or replaced. The Maintenance Technician was unaware of any repair requests, although such repairs are typically same-day. The Administrator stated that all staff should report damaged items immediately, as per the facility's policy to maintain a neat and comfortable environment.
The facility failed to ensure that a resident with dysphagia, Alzheimer's disease, and dementia was assisted by a qualified staff member. An Activity Specialist, not a CNA, was observed feeding the resident, despite the facility's policy prohibiting Feeding Assistants/Resident Attendants from assisting residents with complicated feeding problems.
Failure to Provide Close Supervision and Follow Swallowing Precautions for Resident at Risk of Choking
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement ordered swallowing precautions for a resident with known dysphagia and Parkinsonism who was at risk for choking. The resident had diagnoses including Parkinsonism, dementia, and dysphagia (oropharyngeal phase), and his speech therapy discharge summary documented fluctuating cognition and a need for varying cues to use safe swallowing strategies. Speech therapy recommendations and swallow guidelines required the resident to be seated upright at 90 degrees during meals and for 30 minutes after, to take small bites and sips at a slow rate, to alternate food and liquids, to clear the mouth between bites, to avoid talking while eating, and to receive close supervision with staff maintaining eyes on him to provide cues. On the date of the choking episode, the resident was eating a pureed diet at a table with other residents. Multiple staff members, including a restorative CNA and the nursing supervisor, reported that the resident was known to eat fast and take big spoonfuls of pureed food. During the meal in question, the restorative CNA was seated at the same table but was focused on feeding another resident and was not watching the resident at risk; he stated he did not know whether the resident was alternating food and liquids, eating too fast, or taking big spoonfuls. The nursing supervisor was seated at another table assisting a different resident and did not have continuous visual supervision of the resident at risk. Staff described hearing noises, then observing the resident turning red and appearing unable to cough, at which point the nursing supervisor was called over. The resident experienced a choking episode characterized by facial redness and lip color change, with the nursing supervisor determining he was in distress and performing multiple abdominal thrusts until the resident produced a weak then more pronounced cough and audible noises, though no food was expelled. The resident later reported that he had been eating too fast and thought he was eating a sandwich when he took a big spoonful. Prior to and at the time of survey, staff, including the DON and speech therapist, acknowledged that the resident’s swallowing ability and cognition fluctuated, that he was known to eat quickly, and that close supervision required staff to sit with him and keep eyes on him to provide reminders for small bites, slow rate, and alternating food and liquids. Despite these known risks and established swallow guidelines, staff were simultaneously feeding or assisting other residents and did not maintain the close, continuous supervision described in the resident’s care plan and therapy recommendations, leading to the choking incident. At a later observation, the resident was again seen self-feeding pureed foods while a restorative CNA sat next to him and provided verbal cues to take smaller bites and eat more slowly, confirming that he continued to require close supervision and cueing for safe swallowing. The record review, staff interviews, and observations collectively showed that, at the time of the choking event, the facility did not ensure that staff maintained direct visual supervision and consistent implementation of the prescribed swallowing precautions for this resident at risk for choking.
Failure to Implement Care-Planned Floor Mattress for Resident With Fall History
Penalty
Summary
The facility failed to ensure that fall-prevention interventions were in place for a resident with a known history of falls. The resident’s face sheet dated 1/26/26 documented a diagnosis that included a history of falling, and the fall care plan initiated on 7/7/24 indicated the resident had fallen at the facility and had a history of falling out of bed. The care plan listed use of a floor mattress as an intervention. However, on 1/26/26 at 10:14 AM, the resident was observed in bed with no floor mattress on the floor next to the bed; instead, the mattress was propped up against the wall near the head of the bed, and no staff, family, or caregivers were present in the room. On 1/27/26 at 12:07 PM, a CNA stated that floor mattresses should be placed on the floor next to the bed when the resident is in bed. This deficiency reflects that the facility did not implement the care-planned intervention of a floor mattress for a resident with a documented history of falls and falling out of bed, despite staff acknowledging that the mattress should be in place when the resident is in bed.
Failure to Secure and Account for Narcotic Medication
Penalty
Summary
A narcotic medication, hydrocodone, intended for a resident who was admitted following a hospital stay for pneumonia and respiratory failure, was delivered to the facility by the pharmacy. The medication was received and signed for by a night shift RN, who, due to being busy, placed the narcotic on a medication tray inside the medication room without signing it in or securing it in the required locked narcotic box. The day shift RN, also occupied with other duties, did not secure the narcotic and left it in a bin on top of the shredder in the nurses' station. The medication was not properly stored or logged as required by facility policy and DEA regulations. The narcotic remained unsecured and unaccounted for until it was discovered missing two days later. The DON became aware of the missing medication and conducted an investigation but was unable to determine its whereabouts. Facility policy requires that controlled substances be immediately signed in and stored in a double-locked compartment, with access limited to authorized staff and shift counts performed. These procedures were not followed, resulting in the loss of the narcotic medication.
Failure to Ensure Safe Resident Transfers and Incontinence Care
Penalty
Summary
The facility failed to ensure a safe environment for resident transfers and incontinence care, leading to a fall and injury. Resident R1, who has impaired cognition and vision, is always incontinent and dependent on staff for mobility. During an incontinence care session, R1 fell from the bed and sustained a femur fracture. The incident occurred when a CNA attempted to provide care alone, despite R1 typically requiring assistance from two staff members. The CNA was unable to support R1's weight, resulting in R1 being lowered to the floor, causing the injury. Additionally, the facility did not adhere to the required two-person assist protocol for resident R2 during a transfer. R2, who is a high fall risk and requires two-person assistance, was being transferred by a CNA who was unaware of the need for additional help. During the transfer, R2 became agitated, and the CNA had to lower her to the floor to prevent a fall. The CNA later learned that R2 was supposed to have two-person assistance, highlighting a communication failure regarding care requirements. The facility's failure to provide adequate supervision and assistance during resident care and transfers resulted in unsafe conditions and injuries. The care plans and assignment sheets did not clearly communicate the necessary level of assistance for residents, leading to staff being unaware of the proper protocols. This lack of communication and adherence to care plans contributed to the incidents involving R1 and R2.
Cross-Contamination in Dishwashing and Thickener Storage
Penalty
Summary
The facility failed to ensure proper hand hygiene and cross-contamination prevention in the dishwashing process. During an observation, a dishwasher was seen moving between handling dirty and clean dishes without changing gloves or washing hands, which is against the facility's Hand Hygiene and Infection Control Policy. The Director of Dining Services confirmed that the dishwasher should have washed hands when transitioning from dirty to clean dishes to prevent cross-contamination. Despite the policy requiring hand washing before handling clean utensils, the dishwasher continued to handle both dirty and clean dishes with the same gloves, increasing the risk of contamination. Additionally, the facility did not store thickener in a manner that prevents cross-contamination. A cook was observed using a measuring cup buried in a container of thickener to scoop and add thickener to food. The cook left the measuring cup inside the thickener container, and later used the same cup to scoop more thickener, leaving two measuring cups in the container. The Director of Dining Services acknowledged that storing scoops or measuring cups inside the thickener container is not appropriate due to the risk of cross-contamination. The facility's policy on storage of utensils requires them to be stored in a way that prevents contamination, which was not followed in this instance.
Failure to Verify Feeding Tube Placement Before Administration
Penalty
Summary
The facility failed to check the placement of a feeding tube before administering a nutritional supplement to a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's disease, dysphagia, dementia, epilepsy, and protein-calorie malnutrition. The resident, identified as R25, had a gastrostomy tube (G tube) for nutrition. On a specific day, a registered nurse (V9) administered enteral feeding to R25 without verifying the tube's placement, as required by the facility's protocol. V9 admitted to not checking the placement because she did not have her stethoscope, which she usually uses for the aspiration method to ensure the tube is correctly positioned in the stomach. The Director of Nurses (V2) confirmed that nurses should check the placement of the feeding tube using methods such as aspiration, residual volume, or visual markers on the tubing before administering any substances. The facility's Enteral Nutrition policy also mandates verifying tube placement before administering medications, tube flushes, or enteral formula. The failure to check the tube's placement could potentially lead to an infection in the abdominal wall if the tube is not correctly positioned. R25's care plan highlighted the risk of aspiration pneumonia due to the use of a feeding tube, with interventions including checking for placement and gastric contents per facility protocol.
Improper PPE Use for Resident with Catheter
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) to prevent cross-contamination for a resident with a urinary catheter. During an observation, a Certified Nurse Aide (CNA) was seen assisting the resident with transfers and toileting without wearing a gown, despite the presence of signage indicating the need for enhanced barrier precautions, including gowns and gloves, for high-contact care activities. The resident confirmed that staff usually wear gloves but not always gowns during such activities. Interviews with the Infection Control Preventionist and the Director of Nurses confirmed that the facility's policy requires the use of gowns and gloves during high-contact care for residents with catheters. The CNA admitted to not wearing a gown during the transfer, acknowledging the requirement to do so. The facility's Enhanced Barrier Precautions policy specifies that PPE is necessary for activities such as dressing, transferring, and toileting, especially for residents with urinary catheters, to prevent the transfer of microorganisms.
Resident Dignity Not Maintained During Dining
Penalty
Summary
The facility failed to maintain the dignity of a resident during dining, as observed in the case of a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's Disease and dementia. The resident was found by her daughter in the group dining room wearing only a hospital-type nightgown with a blanket draped over her shoulders, despite having appropriate clothing available. The daughter had brought clothes, including pajamas, to the facility the day before. The resident appeared ungroomed, with messy hair, which prompted the daughter to complain to the staff. The Social Service Director and the Director of Nurses acknowledged the incident, confirming that the resident was not dressed appropriately before being taken to the dining room. The Director of Nurses stated that all residents should receive morning care, including being dressed and groomed, before leaving their rooms. The facility's Quality of Life policy emphasizes maintaining personal privacy and encouraging residents to dress in their own clothing rather than hospital-type gowns. The incident was recognized as undignified and not in line with the facility's normal procedures.
Failure to Maintain Homelike Environment Due to Damaged Nightstand
Penalty
Summary
The facility failed to ensure a homelike environment by allowing a damaged nightstand to remain in a resident's room. A resident's relative reported that the nightstand was damaged during the entire week her aunt resided in the facility, with the top handle hanging off and a section missing from the left upper corner. Despite staff frequently entering and exiting the room, the nightstand was neither repaired nor replaced. The current resident in the room confirmed that the nightstand had been in the same condition since her arrival. The Maintenance Technician was unaware of any complaints or repair orders for the nightstand, although he stated that such items could typically be repaired the same day they are reported. The Administrator acknowledged that damaged items should be reported immediately by all staff, as they reflect poorly on the facility's environment. The facility's policy emphasizes maintaining a homelike, sanitary, and orderly environment.
Unqualified Staff Feeding Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with a complicated feeding problem was assisted by a qualified staff member. On 05/08/24 at 11:35 AM, an Activity Specialist, who was not a Certified Nursing Assistant (CNA), was observed feeding a resident diagnosed with dysphagia, Alzheimer's disease, and dementia. The resident's condition required careful feeding to prevent choking and aspiration. The Speech Therapist confirmed that the resident was at risk for choking if not fed appropriately. The resident's diet orders specified a pureed diet with nectar thick liquids and required the mouth to be cleared before each bite or sip. The facility's policy did not allow Feeding Assistants/Resident Attendants to assist residents with complicated feeding problems, yet this policy was not followed in this instance.
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 1,009 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — 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 Lake Forest
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Claridge Healthcare Center | 1.8 mi | ★★★★★ | 9 | 2 |
| Warren Barr North Shore | 4.1 mi | ★★★★★ | 16 | 0 |
| Avantara Libertyville | 4.2 mi | ★★★★★ | 3 | 1 |
| Serenity Estates Of Lincolnshire | 5.1 mi | ★★★★★ | 17 | 2 |
| Aliya Of Highwood | 5.2 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lake Forest Place.
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.