Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Lake Forest Village by PureHealth
DENTON, TX · 60 certified beds · Last Life Safety survey September 11, 2025
CMS Certification Number 455685 · first certified February 1987
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: Lake Forest Village by PureHealth (3901 Montecito Drive). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Operated by PUREHEALTH · For profit - Limited Liability company
- Ownership changed November 1, 2024 (change of ownership)from THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Position within TX
11 citations — more than 68% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys on file averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: October 2026 to November 2026. This facility’s last Life Safety survey was September 2025. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,923 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 11 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 11 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 11 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 22, 2023 | 3 |
| August 8, 2024 | 4 |
| September 11, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-08-08 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-08-08 |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | 1 | 2025-09-11 |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | 1 | 2024-08-08 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2025-09-11 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2025-09-11 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2023-06-22 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2025-09-11 |
What the citations cover
- Smoke Deficiencies 9
- Egress Deficiencies 1
- Emergency Preparedness Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Egress Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 11, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (October 10, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (October 10, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 10, 2025) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (October 10, 2025) |
August 8, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 4, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 4, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (September 4, 2024) |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | Deficient, Provider has date of correction (September 4, 2024) |
June 22, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 19, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 19, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 19, 2023) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.