Above 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 Village By Purehealth during CMS and state inspections, most recent first.
A resident with post-CVA hemiplegia, aphasia, and significant ADL dependence was observed in bed without access to her call light, which was tucked behind the bed frame on her affected side. She used a tablet to report that her call light was often not within reach and that she sometimes had to wait for staff rounds or contact her representative for help, especially when essential items were not left nearby. A CNA acknowledged that after repositioning the resident she may have failed to re-clip the call light within reach, despite recognizing its importance due to the resident’s limited mobility. An RN stated call lights should always be within reach and never behind the bed, and the DON confirmed facility protocol requires CNAs to ensure call lights are accessible. The resident’s representative reported repeatedly finding the call light out of reach and having previously raised this concern with the facility.
Expired food items were found in the pantry and refrigerator, including powdered sugar and mushrooms past their use-by dates, and the ice machine scooper bin was cracked with heavy calcium buildup. The DD acknowledged the kitchen sanitation and storage lapses, and the ADMIN stated that opened items needed to be dated and expired or unsafe foods discarded per facility policy.
Failure to Submit Accurate PBJ Staffing Data: The facility failed to submit complete and accurate PBJ staffing data to CMS for the quarter reviewed. Casper3 showed triggers for One Star Staffing Rating, Excessively low Weekend Staffing, No RN hours, and Failed to have Licensed Nursing Coverage 24 hours/day, with no RN hours and no licensed nursing coverage reported for every day in October. The DON stated she was working during that month and there would have been no days without a working RN, while HR and the ADMIN said the issue was tied to the change of ownership and missing prior employee files.
Unsecured Resident Medical Information Left Visible on Nursing Cart: An LVN left her cart unattended in front of the nurses’ station with a paper showing resident medical information visible to others. The paper listed details for three cognitively intact residents, including skilled nursing status, UA needs, antibiotics, TAR changes, and other active orders. The LVN said she routinely wrote shift notes on paper and was unsure whether the information was medical information, while the DON and ADON stated such information should not be left unattended because it is confidential and could be seen by unauthorized individuals.
Incomplete Care Plans for Chronic Conditions: The facility did not develop complete person-centered care plans for several residents with diabetes, HTN, or HLD. One resident’s diabetes plan lacked insulin, dietary, blood sugar, and hypo/hyperglycemia monitoring interventions, and another resident with diabetes and severe cognitive impairment had a similarly limited plan despite insulin orders. Two residents had HTN documented and medication orders but no HTN care plans, and one resident with HLD had no HLD care plan. Interviews showed the MDS Coordinator believed ordered treatments did not need to be included, while the DON stated care plans should be specific and include the resident’s problems, goals, and interventions.
Improper Storage of Medications and Wound Care Supplies: A tube of zinc oxide was left on two residents’ side tables, a PRN tramadol was left for a resident to take unsupervised, and wound care supplies were left on another resident’s dresser. The residents involved included cognitively intact residents with incontinence and skin breakdown risk, a resident with acute pain and a femur fracture, and a resident with severe cognitive impairment and a skin tear. Staff stated the items should have been kept in drawers, carts, or other secured storage and not left accessible in the rooms.
Staff failed to follow infection control precautions during multiple resident care activities. A CNA transferred a resident with a catheter without a gown, two CNAs handled catheter tubing and changed gloves without proper hand hygiene, another CNA used gloves taken from a pocket without sanitizing hands, an LVN connected IV antibiotics for a resident with a PICC line without a gown, and two therapy staff assessed and repositioned a resident with a surgical wound without gowns. The report states these actions were inconsistent with EBP and hand hygiene expectations.
Improper Sacral Pressure Ulcer Cleaning: An LVN provided wound care to a resident with an unstageable sacral pressure ulcer by using the same gauze back and forth across the wound and touching the surrounding skin during cleansing and drying. The resident was cognitively intact and had a care plan and MD order for wound cleansing, pat drying, and dressing application. The DON, ADON, and Administrator stated the technique was improper and could introduce microorganisms or bacteria into the wound.
A resident with a right femur fracture, acute pain, and HLD was given PRN Tramadol and left to take it unsupervised without any self-administration assessment or order. Surveyors also found an expired Atorvastatin bottle in the med cart, which staff had placed there without checking the expiration date. Interviews confirmed staff left the medication at bedside and did not verify the expired bottle before storing it in the cart.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring her call light was within reach while in bed. The resident was an adult female with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, aphasia, dysphasia, anoxic brain damage, chronic pain, anxiety disorder, and major depressive disorder. Her significant change MDS showed a BIMS score of 14, indicating intact cognition, and Section GG documented that she required maximal assistance with most ADLs. Her care plan identified an ADL self-care performance deficit related to paraplegia/post-CVA affecting the left side, and indicated she could move up in bed, turn side to side, and sit on the side of the bed with cueing and assistance from one to two staff. During observation, the resident was lying in bed, using her electronic tablet to communicate due to aphasia, and was unable to move her left arm but could use her right arm to reach nearby items. She communicated via the tablet that she often could not get help when needed because her call light was usually not within reach, and when her door was closed staff could not see her waving for help. She reported that staff generally came in about every two hours, but she sometimes needed help sooner, especially when essential items were not left within reach on her bedside table, which caused her frustration and discomfort. Observation of the room at that time showed the call light cord coming from the wall on the left side and tucked behind the bed frame, leaving her without access to the call light to directly notify nurses. Staff interviews confirmed the resident’s limited mobility and reliance on the call light and tablet for assistance. A CNA stated the resident could use her right arm but could not fully turn without assistance and that it was important for the call light to be clipped near the resident’s chest or on the bed sheet due to her limited mobility. The CNA recalled the call light being within reach earlier when passing the breakfast tray but acknowledged that after repositioning the resident she may have moved the call light away and forgotten to clip it back within reach. An RN stated call lights should always be within residents’ reach and never tucked behind the bed and was not aware that this resident’s call light was behind the bed. The DON stated the resident was physically dependent on staff on one side, communicated primarily through her tablet and other signals, and that it was protocol for CNAs to ensure call lights were within reach before leaving rooms. The resident’s representative reported ongoing concerns that staff sometimes forgot about the resident, that the call light was often out of reach, and that this concern had been raised with the facility several times. The facility’s Resident Rights policy stated that residents have rights including communication with and access to people and services inside and outside the facility.
Expired Food Items and Unsanitary Ice Scooper Storage
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen, which was the only kitchen reviewed for food and nutrition services. During an observation on 09/09/2025, surveyors found one wrapped bag of powdered sugar on the top shelf of the pantry labeled with a prep date of 09/02/25 and a use-by date of 09/08/25. In one of the refrigerators, three stainless steel containers of mushrooms were observed on the middle shelf, labeled 09/04 with a use-by date of 09/07. The ice machine scooper bin was also observed to be cracked and had a thick calcium buildup around the bottom. During interviews, the DD stated he had been the DD for about 6 years and acknowledged the observations. He stated he was responsible for kitchen sanitation and proper storage of food products and said the deficient practices were oversighted. He stated the powdered sugar appeared to be out of place and may have been set down by staff and forgotten. He also stated that if food items were not dated when opened, staff would not know how long they would last, that refrigerated items must be dated upon receipt unless they already have a manufacturer date, and that the fridge and freezer should be checked daily for spoiled foods. The ADMIN stated he oversaw all departments, that everything needed to be dated, and that opened items needed an open date and expiration date. The facility policy stated that foods that have been opened or prepared are to be dated, labeled, and stored properly, and that expired or unsafe foods are to be discarded.
Failure to Submit Accurate PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate PBJ staffing information to CMS for the first quarter of FY 2025, including agency and contract staff, based on payroll and other verifiable and auditable data in the required uniform format. Record review of the Casper3 PBJ report showed four triggered areas on the FY Quarter 1 report: One Star Staffing Rating, Excessively low Weekend Staffing, No RN hours, and Failed to have Licensed Nursing Coverage 24 hours/day. The report detailed no RN hours for every day in October 2024 and failed licensed nursing coverage 24 hours/day for every day in October 2024. During interviews, the DON stated she had been working at the facility for 4 years and said she was working during October and there would have been no days without a working RN. The HR staff stated the facility used a vendor to submit information, but the facility was still responsible for meeting requirements, and said that for 10/1/24 through 10/31/24 they could not get employee files from the previous owners. The ADMIN stated the facility was aware the PBJ data had not been submitted for Quarter 1, said there was a change of ownership effective November 1, 2024, and stated the previous company said it would submit the PBJ data to CMS. The ADMIN also stated the corporate office enters the PBJ information and that the issue was related to the change from one company to the new company.
Unsecured Resident Medical Information Left Visible on Nursing Cart
Penalty
Summary
The facility failed to keep confidential medical records secure when an LVN left her cart unattended in front of the nurses’ station with a piece of paper containing resident medical information visible to others. The paper included information for three residents and was facing the hallway while the LVN went inside a resident’s room. The information written on the paper included that one resident was on skilled nursing and needed urinalysis, another was on skilled nursing, antibiotics, and had a zinc order changed in the TAR, and a third resident was on skilled nursing. Resident records showed that the three residents had active medical issues and were cognitively intact. One resident was admitted for infection and inflammatory reaction due to an internal joint prosthesis and had an order for IV daptomycin after right shoulder surgery. Another resident was admitted for acute kidney failure and urinary retention and had orders for urine culture, UA, and zinc oxide for redness. The third resident was admitted for a right foot fracture and had pain management orders related to the fracture. During interview, the LVN stated she routinely wrote a brief summary of tasks and resident information on a piece of paper for her shift and was unsure whether what she wrote was medical information. She said she guessed she should have flipped the paper before leaving the cart if it contained medical information. The DON and ADON stated that resident medical information should not be left unattended because it is confidential and could be seen by unauthorized individuals, including visitors and other persons who might understand the information. The facility policy stated that resident personal privacy and confidentiality of all resident personal and medical records would be safeguarded.
Incomplete Care Plans for Chronic Conditions
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for four residents whose comprehensive assessments identified diabetes, hypertension, or hyperlipidemia. For Resident #7, the care plan dated 08/25/2025 addressed diabetes only with interventions such as checking body parts, licensed nurse foot care, and ensuring dry socks, but did not include that the resident was receiving insulin, a dietary consult, fasting blood sugar checks, or monitoring for signs and symptoms of hyperglycemia and hypoglycemia. The record also showed a physician order for insulin lispro before meals and at bedtime for type 2 diabetes. Resident #7 also had hypertension documented on the MDS and face sheet, with a physician order for losartan 12.5 mg daily, but the comprehensive care plan did not include a hypertension care plan. Resident #9 had type 2 diabetes with diabetic neuropathy, severe cognitive impairment with a BIMS score of 03, and a physician order for Humalog before meals for elevated A1C, yet the diabetes care plan only included observing the resident and family’s ability to manage treatment and encouraging good general health practices. That care plan did not reflect insulin use, dietary consultation, fasting blood sugar monitoring, or monitoring for hyperglycemia and hypoglycemia. Progress notes also documented insulin-related activity, including no insulin required for a blood sugar of 141 and a later order for insulin lispro 5 units SQ before meals. Resident #35 had hypertension on the MDS and a physician order for lisinopril 20 mg daily, but no hypertension care plan was present. Resident #37 had hyperlipidemia on the MDS and a physician order for atorvastatin 10 mg daily, but no hyperlipidemia care plan was present. During interviews, the MDS Coordinator stated she was responsible for care plans and believed conditions already covered by orders did not need to be included, while the DON stated care plans should be person-centered, tangible, specific, and include the problem, goals, and interventions, including diabetes and hypertension when present.
Improper Storage of Medications and Wound Care Supplies
Penalty
Summary
The facility failed to ensure medications and wound care products were stored in locked compartments and kept out of residents’ reach for four residents. During observations, a tube of zinc oxide was found on the side table in Resident #11’s room, and another tube of zinc oxide was found on Resident #44’s side table. Resident #11 was cognitively intact, incontinent of bowel and bladder, and at risk for pressure ulcers/injuries; Resident #44 was cognitively intact, incontinent of bowel and bladder, and also had a care plan goal to remain free from skin breakdown. Both residents had no physician order for barrier cream documented in the record reviewed. For Resident #37, who was cognitively intact and had a fracture of the right femur with acute pain, a physician order was in place for tramadol 50 mg PRN. During observation, a small plastic cup containing one pill was left on the resident’s food tray, and the resident took the medication herself after being told by the nurse to take it after breakfast. LVN A stated she had given the tramadol as a PRN and should have ensured the resident swallowed it before leaving the room. For Resident #60, who had severe cognitive impairment and a skin tear, wound care supplies including xeroform, petroleum dressing, and calcium alginate were observed on top of the dresser in the resident’s room. The resident was not in the room at the time of observation. LVN A stated she did not know who left the wound care materials there and that they should have been kept in the cart or the resident’s drawer. The DON and ADON stated zinc oxide and wound care materials should not be within residents’ reach and should be stored with the wound care supplies or in the cart when not in use.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for five residents who had conditions requiring enhanced barrier precautions or hand hygiene precautions. The report identified failures involving a resident with an indwelling catheter, a resident with a catheter after a shower and mechanical lift transfer, a resident needing assistance with toileting, a resident receiving IV antibiotics through a PICC line, and a resident with a surgical wound after knee replacement surgery. Survey observations and staff interviews documented that staff did not consistently follow the facility’s infection control expectations during resident care activities. For the resident with an indwelling catheter and enhanced barrier precautions, CNA B transferred the resident from bed to wheelchair without wearing a gown, even though a sign outside the room indicated gown use was required during transfer. For the resident with a catheter after showering, CNA F and CNA G transferred the resident with a mechanical lift and handled the catheter tubing during repositioning and sling removal. During that care, CNA G changed gloves without sanitizing hands first, and CNA F touched the catheter tubing and then continued care without changing gloves. Both CNAs acknowledged during interview that hand hygiene should have been performed between glove changes and that the tubing could have been contaminated. For the resident needing toileting assistance, CNA F pulled gloves from her pocket and put them on without performing hand hygiene, then later placed additional gloves in her pocket and reused them after waiting for the resident to finish in the bathroom. CNA F stated she was not sure her pocket was clean and said she would not put gloves in her pocket again. For the resident receiving IV antibiotics through a PICC line, LVN A entered the room and connected the IV without wearing a gown despite signage requiring gown use for central line care; she also returned to disconnect the IV without a gown on an earlier attempt. For the resident with a surgical wound to the right knee, PTA D and PT E entered the room without gowns and attempted to assess, reposition, and transfer the resident while wearing gloves. Both therapists stated they were evaluating the resident’s ability to transfer and repositioning him because he was in pain, and they did not think a gown was needed.
Improper Sacral Pressure Ulcer Cleaning
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for a resident with an unstageable sacral pressure ulcer. The resident was cognitively intact with a BIMS score of 13 and had a diagnosis of a sacral fracture. Her care plan included treatment for the sacral pressure ulcer, and the physician order directed staff to clean the wound with wound cleanser or normal saline and pat dry, then apply collagen powder, alginate, and border gauze. During observation of wound care, an LVN prepared the supplies and began treatment to the resident’s sacral pressure ulcer. After removing the old dressing, she cleaned the wound with normal saline using gauze, but used the same gauze repeatedly to wipe the wound upward and downward four times. The observation also showed the wet gauze touched the surrounding skin of the pressure ulcer. She then used gauze to pat dry both the wound and the surrounding skin before applying collagen powder and covering the area with a dressing. In interview, the LVN stated the gauze should not have been reused and that wound care should be performed from inside to outside, discarding the gauze after each use. The DON stated the gauze should be changed after every stroke and should not go back and forth on the wound, and the ADON stated the same gauze could introduce microorganisms back into the pressure ulcer and that touching surrounding skin could introduce bacteria to the wound. The Administrator stated improper wound care could lead to infection. The facility policy on wound care was requested but not provided prior to exit.
Unsupervised Tramadol Administration and Expired Atorvastatin in Medication Cart
Penalty
Summary
The facility failed to ensure that Resident #37 was not self-administering Tramadol without an assessment. Resident #37 was a cognitively intact female admitted with a right femur fracture, acute pain due to trauma, and hyperlipidemia. Her quarterly MDS reflected a BIMS score of 15 and acute pain, and her care plan addressed pain management but did not indicate that she could self-administer medications. The physician order for Tramadol 50 mg every 6 hours as needed did not include self-administration, and the clinical assessment on 09/09/2025 showed no assessment for self-administration, no clear instructions for self-administration, and no determination that she was competent to manage her own medications. During observation on 09/09/2025, the resident was seen in bed with a small plastic cup containing one pill on her food tray. She took the medication herself and stated that the nurse had left it there and told her to take it after breakfast. She said the medication was Tramadol requested for pain after therapy. In interview, the LVN stated she gave the resident one Tramadol as a PRN and thought the resident took it, but acknowledged she should have ensured the resident swallowed it before leaving the room. She stated medications should not be left with the resident because the resident might not take them, throw them, or choke while taking them and no one would know. The facility also failed to ensure there was no expired medication inside the medication cart. On 09/10/2025, surveyors observed a bottle of Atorvastatin for Resident #37 in the medication cart dated 10/07/2024. The MA stated she had administered the resident’s atorvastatin earlier from the blister pack and had not checked the expiration date on the bottle. Another MA stated the bottle had been placed in the cart by the nurse and was not checked. The admitting RN stated she had received medication bottles from a family member and placed them in the cart without checking them, and she later noticed the bottle was old and the words could not be read. The DON, ADON, and Administrator all stated medications should not be left with residents unsupervised and expired medications should not be in the cart; the facility policy also required checking expiration dates and allowing self-administration only when the physician and interdisciplinary team determined the resident had the capacity to do so safely.
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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 Denton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Denton Rehabilitation And Nursing Center | 2 mi | ★★★★★ | 4 | 0 |
| University Rehabilitation Center | 2.3 mi | ★★★★★ | 7 | 1 |
| Corinth Rehabilitation Suites On The Parkway | 3.7 mi | ★★★★★ | 18 | 0 |
| Vintage Health Care Center | 4.6 mi | ★★★★★ | 24 | 0 |
| Cottonwood Nursing And Rehabilitation | 5.3 mi | ★★★★★ | 17 | 0 |
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