Lake Forest Senior Living At Mountain Home

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

57.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 161 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 61.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 70 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 70 beds and averages 49.6 residents a day — about 71% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.51 hrs/resident/day on weekends vs 4.07 on weekdays — 14% thinner on weekends. RN hours go from 0.50 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

• Potential for harm · E2025-06-27 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interview, and facility policy review, the facility failed to ensure an abuse policy was implemented and monitored that included a training program regarding abuse prevention required to be provided to staff, potentially affecting all residents that resided in the facility. The findings include: A review of the [City and State name] Success Center Transcript Report, received via email from previous management on 06/27/2025 at 11:13 AM, revealed the facility had 26 current staff members who either did not have documented abuse training or had not had documented abuse/neglect training since 08/02/2024, when the current management was put into place. A review of the [City and State name] Success Center Transcript report revealed the following staff members had not had any documented abuse training since February of 2024; the Environmental Supervisor - 02/26/2024, the Activity Manager - 02/06/2024, the Activity Supervisor - 02/01/2024, Recreation Aide #20 - 02/04/2024, the Chaplin - 02/12/2024, Laundry #1 - 02/05/2024, Certified Nursing Assistant (CNA) #2 -…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-27 · tag F0947 — failed to train nurse aides adequately — pattern
  Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility record review, interviews, and policy review, the facility failed to ensure direct care staff were trained annually for Abuse/Neglect prevention and required in-service training for nurse aides, which potentially affected all residents that resided in the facility. The findings include: A review of the [City and State name] Success Center Transcript Report, received via email from the previous management, on 06/27/2025 at 11:13 AM, revealed the facility had six current Certified Nursing Assistants (CNAs) who had not had documented abuse neglect training since the new management started 08/02/2025. The following are CNA ' s who had no training in over a year with the last documented training date: CNA #2 - 02/11/2024, CNA #3 02/15/2024, CNA #17 - 04/01/2024, CNA #22 - 05/07/2024, Restorative Nursing Assistant #12 - 03/08/2024, and Recreation Aide #20 - 02/04/2024. During an interview on 06/26/2025 at 4:09 PM, the Director of Nursing (DON) provided a training document titled General Orientation for 2024, dated 12/18/2024, that included elder abuse as part of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-05-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure the kitchen and kitchen equipment were maintained in clean condition; and failed to ensure food items were sealed, labeled, and dated; The failed to ensure expired food and supplements were removed to prevent the potential for food borne illness; and the facility failed to ensure staff performed hand hygiene during meal service for 5 (Resident #3, 20, 24, 25 and 29) of 5 residents observed during the 11:30 AM meal service for infection prevention and control. This failed practice had the potential to affect all 32 residents that receive their meals from the facilities kitchen. The findings are: On 05/06/2024 09:14 AM, the Nurse's Kitchen near the common day area was assessed with Licensed Practical Nurse (LPN) #5. There were 2-32-ounce containers of Vanilla Med Plus (no sugar added) with a best if used by date of April 20, 2024, in the side door. There was 1-32-ounce Butter Pecan Nutritional Drink with a best if used by date of May 4, 2024, in the side door. On 05/06/2024 at 09:16 AM, Licensed Practical…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-05-08 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure nurse coverage on 11-26-2023 on the 6:00 PM to 11:59 PM shift as evidenced by the shift report. The lack of coverage had the potential to affect all residents during the shift, that are dependent on the nurse for their care. The findings are: 1. 05/06/24 at 2:28 PM, staffing days in question 11/25 Saturday (SA); 11/26 Sunday (SU); 12/09 (SA); 12/10 (SU); 12/17 (SU); and 12/23 (SA) 2. On 05/06/24 at 1:26 PM, the Administrator provided 24-hour shifts reports. The date of 11/26/2024 showed no nurse coverage. 3. On 05/08/2024 at 10:20 AM, the Surveyor asked Certified Nursing Assistance (CAN) #6 if she thought there were enough staff to cover the care for the residents, to which she replied yes, and they're still hiring. 4. On 05/08/2024 at 10:28 AM, the Surveyor asked the Director of Nursing (DON) if she thought there was enough coverage to care for all the residents. She assured me they had enough coverage to care for all the residents. 5. On 05/06/2024 at 2:28 PM, the Administrator said, Shifts Report…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-05-08 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: [NAME], [NAME] Based on observations, interviews, record review, facility document review, and facility policy review the facility failed to ensure a resident received all doses of a physician ordered antibiotic for 1 (Resident #9) of 9 residents reviewed for medication administration. Findings include: A review of a facility policy titled, Medication: Administration Including Scheduling and Medication Aides- R/S, LTC, with a reviewed/revised date of 03/29/2024, indicated, Purpose . To administer medications correctly and in a timely manner page 2 of 8 Medication Errors An incident will be completed for all medication errors. Page 6 of 8 8. Administer medications within at least 60 minutes on each side of ordered time, . 10. Document that the medication was given as soon as possible after administration. A review of the Medication Administration Competency Checklist Clinical Skill Checklist, indicated the facility performed a competency check on Licensed Practical Nurse (LPN) # 1 on 03/01/2024. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-05-08 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure expired medications and supplies were disposed of; and the facility failed to ensure medications and wound treatment supplies were stored and contained safely to prevent the accidental ingestion and or injury. The findings are: A review of a facility policy titled, Medications: Acquisition Receiving Dispensing and Storage, dated 3/29/2024, revealed, Purpose: to ensure that medications are stored according to manufacturers' recommendations. Medications will be stored in a locked medication cart, drawer or cupboard. Only the person passing medications and the director of nursing services and/or designee will be permitted to have access to the keys to the medication storage areas. The location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations. All medications will be stored in accordance with manufacturers' recommendations. On 05/05/2024 at 2:49 PM, surveyor observed the following sitting on the top of a dresser in Resident #16's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-05-08 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure staff performed hand hygiene during meal service for 5 (Resident #3, 20, 24, 25 and 29) of 5 residents observed during the 11:30 AM meal service for infection prevention and control and failed to ensure staff donned appropriate PPE during resident medication administration for 1 (Resident #9) of 9 residents observed during medication administration. This failed practice had the potential to affect all residents in the facility who received meals from the dietary department and all residents receiving medication. Findings include: A review of a facility policy titled, Hand hygiene - Enterprise with a review/revised date of 03/29/2022 described a Patient Zone as a concept related to the 'geographical' visualization of key moments for hand hygiene. It contains the patient and their immediate surroundings. and the Health-care Zone as a concept related to 'geographical' visualization of key moments for hand…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-05-08 · tag F0882 — pattern
  Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to assure a certified Infection Control Preventionist (ICP) was employed and available at least 20 hours a week, to establish and maintain the infection prevention program to help prevent the development and transmission of communicable diseases and infections. The findings are: Review of a facility policy titled, Infection Prevention and Control Program, All Service Lines, dated 10/30/2023, revealed, Purpose: To establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and conformable environment, and to help prevent the development and transmission of communicable diseases and infections. Infection Preventionist: The individual designated by the Skilled Nursing facility (SNF) to be responsible for the Infection Prevention and Control Program. The Skilled Nursing Facility has designated at least one individual as the Infection Preventionist, who is responsible for the facility's Infection Prevention and Control Program. A review of the Nursing Home Infection Preventionist…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-05-08 · tag F0908 — failed to keep essential equipment working — pattern
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure kitchen equipment was clean and in good working order to prevent the spread of infection and food borne illnesses. This failed practice had the potential to affect 32 residents that receive their meals, from the facilities kitchen. The findings are: The following observation were made: 1. On 05/05/2024 at 10:30 AM, a rolling storage shelf had two stock pots full of old oil and food particles. 2. On 05/05/2024 at 10:32 AM, a double door handled oven covered in old grease and sticky. The floor between it and the stove has a layer of dark substance. 3. On 05/05/2024 at 10:33 AM, the stove has a pot cooking with a spoon used for stirring set on the stove top that is greasy and covered in food crumbs. 4. On 05/05/2024 at 10:40 AM, three metal tables are lined up together in the middle of the kitchen. The bottom shelves store metal dishes that have grease and dust on them. There is nothing to cover the dishes while stored. 5. On 05/05/2024 at 10:44 AM, a rolling warming plate container is covered with food…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-01-26 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure restorative therapy services were provided to decrease the potential for further decline in range of motion and maintain normal level of function for 1 (Resident #1) of 3 case mix residents. This failed practice had the potential to affect 5 residents who were receiving restorative therapy services according to the list provided by the Minimum Data Set Coordinator on 1/25/24 at 10:39 am. The findings are: Resident #1 readmitted to facility on 9/26/23 with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Dominant Side. Care plan initiated on 9/26/23 documented, .The resident has a need for restorative intervention due to limited physical mobility/communication problem R/T (related to) hx (history) of CVA (Cerebral Vascular Accident) . On 1/24/23 at 10:15 am during interview of Resident #1, resident confirmed the facility ordered restorative therapy services to start at the end of November. Resident confirmed he had only received restorative services one time on January…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CONTINUUM HEALTHCARE — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in AR