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

New ownershipOwnership changed November 1, 2024 (change of ownership)from THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within TX

11 citations — more than 69% 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

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 4 citations; the earlier surveys in the window 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 opens October 2026 — about 1 month from now. 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 1,905 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 three years in Maryland. 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 ever cited for sprinkler inspection and testing 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

E-0006

Physical environment (health survey)

2 physical-environment citations 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.
F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

How that compares

Citations on file over three years

Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	11
Median facility in TX	7
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
June 22, 2023	3
August 8, 2024	4
September 11, 2025	4

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2024-08-08
K-0324	Provide properly protected cooking facilities.	2	2024-08-08
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	1	2025-09-11
K-0352	Properly install and monitor supervisory attachments on automatic sprinkler systems.	1	2024-08-08
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-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-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

Citations by CMS category

Smoke Deficiencies 9
Egress Deficiencies 1
Emergency Preparedness Deficiencies 1

Citations by CMS category
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

Citations issued on September 11, 2025
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

Citations issued on August 8, 2024
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

Citations issued on June 22, 2023
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 August 1, 2026. Surveys conducted in the last few months may not appear yet.