Lake Forest Village by PureHealth

In the surveyor’s words

From the most serious findings on record at Lake Forest Village by PureHealth, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 13, 2022

  Based on observation, interview and record review, the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement for 1 of 4 residents reviewed for accidents hazards/supervision. (Resident#1) The facility failed to properly supervise Resident #1 who was cognitively impaired and who wore a wander guard due to elopement behaviors. Resident #1 wandered out of the front door of the facility, and she was located 0.9 miles away from the facility. Law Enforcement was notified by someone in the neighborhood. An Immediate Jeopardy (IJ) was identified to have existed from 04/03/22 to 04/03/22 . The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. […]

• No harm, potential for more than minimal, widespreadF812Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. Dietary staff failed to dispose of expired foods items in the pantry and refrigerator. Dietary staff failed to ensure the ice machine scooper was clean and sanitized. These deficient practices could place residents at risk for cross-contamination and foodborne illness.Findings included: Observation on 09/09/2025 from 9:10 AM to 9:45 AM in the facility's kitchen revealed: One wrapped bag of powdered sugar on the top shelf, labeled with a prep date of 09/02/25, with a use by date of 09/08/25. […]

• No harm, potential for more than minimal, widespreadF851Sep 11, 2025

  Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for fiscal year 2025 for the first quarter (October 1, 2024, to December 31, 2024) reviewed for one of one facility administration reviewed.The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for October 1, 2024, to December 31, 2024.This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living… […]

• No harm, potential for more than minimal, patternF583Sep 11, 2025

  Based on observations, interviews, and record review, the facility failed to secure confidential medical records for three (Resident #16, Resident #21, and Resident #61) of eighteen residents reviewed for resident rights. The facility failed to ensure LVN I secured Resident #16, Resident #21, and Resident #61's medical information before leaving her cart on 09/10/2025. This failure could place the residents at risk of not having their medical information exposed to unauthorized individuals. Resident #16 Record review of Resident #16's Face Sheet, dated 09/10/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF656Sep 11, 2025

  Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for four (Resident #7, Resident #9, resident #35, and Resident #37) of fifteen residents reviewed for Care Plans. 1. The facility failed to ensure Resident #7's care plan for diabetes, dated 08/25/2025, had appropriate interventions. 2. The facility failed to ensure Resident #7 was care planned for hypertension. 3. […]