Inspection Reports for
Lake Forest Senior Living at Mountain Home
300 Good Samaritan Dr, Mountain Home, AR 72653, United States, AR, 72653
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 20, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Lake Forest Senior Living at Mountain Home.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 2
Date: Jun 27, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with abuse prevention training requirements and ensure nurse aides received annual training in abuse prevention and dementia care.
Findings
The facility failed to implement and monitor an abuse prevention training program for staff, with many staff members lacking documented abuse training since before new management took over in August 2024. The facility also failed to ensure nurse aides received required annual abuse/neglect prevention training, potentially affecting all residents.
Deficiencies (2)
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, including required staff training.
Failure to ensure nurse aides have the skills needed to care for residents, including required annual abuse/neglect prevention training.
Report Facts
Staff without documented abuse training: 26
Certified Nursing Assistants without documented abuse training: 6
Date of new management takeover: Aug 2, 2024
Planned completion date for training: Aug 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed no abuse or neglect in-service training since new management took over and discussed plans for training completion. | |
| Director of Nursing | Director of Nursing (DON) | Confirmed facility did not have an abuse/neglect training program and no abuse training since new management. |
Inspection Report
Routine
Deficiencies: 8
Date: May 8, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including care planning, nurse staffing, medication administration, medication storage, food safety, infection prevention and control, and equipment maintenance.
Findings
The facility was found deficient in revising care plans, ensuring adequate nurse coverage, medication administration errors, improper storage and disposal of expired medications and supplies, poor kitchen sanitation and food safety practices, failure to perform hand hygiene and use PPE appropriately, lack of a certified Infection Control Preventionist, and failure to maintain kitchen equipment in good working order.
Deficiencies (8)
Failed to revise a care plan for Resident #25 to include ankle-foot orthosis use.
Failed to ensure nurse coverage on 11-26-2023 6:00 PM to 11:59 PM shift.
Failed to ensure a resident received all doses of a physician ordered antibiotic (Resident #9).
Failed to ensure expired medications and supplies were disposed of and stored safely.
Failed to maintain kitchen and kitchen equipment in clean condition and failed to remove expired food and supplements.
Failed to ensure staff performed hand hygiene during meal service and failed to don appropriate PPE during medication administration.
Failed to designate a qualified infection preventionist to be responsible for the infection prevention and control program.
Failed to keep all essential kitchen equipment working safely and clean.
Report Facts
Deficiencies cited: 8
Medication doses missed: 1
Expired nutritional drinks: 7
Temperature: 43.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration error and infection control PPE deficiency |
| LPN #2 | Licensed Practical Nurse | Named in infection prevention hand hygiene and medication administration observations |
| LPN #3 | Licensed Practical Nurse | Interviewed about Infection Control Preventionist status |
| LPN #5 | Licensed Practical Nurse | Interviewed about wound care supplies and expired items |
| LPN #6 | Licensed Practical Nurse | Former certified Infection Control Preventionist, terminated recently |
| Director of Nursing | Director of Nursing | Interviewed about nurse staffing, care plans, infection control, and expired supplies |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed about kitchen equipment and food safety |
| CNA #2 | Certified Nursing Assistant | Observed failing hand hygiene during meal service |
| Administrator | Administrator | Interviewed about Infection Control Preventionist and facility policies |
Inspection Report
Deficiencies: 1
Date: Jan 26, 2024
Visit Reason
The inspection was conducted to evaluate the facility's provision of restorative therapy services to residents, specifically to ensure appropriate care to maintain or improve range of motion and mobility.
Findings
The facility failed to provide restorative therapy services as ordered, with Resident #1 receiving only one session despite a documented need. The facility acknowledged not providing restorative services and is actively working to implement them, with trained CNAs not yet providing these services due to part-time work and other duties.
Deficiencies (1)
Failure to ensure restorative therapy services were provided to decrease potential decline in range of motion and maintain normal function for residents.
Report Facts
Residents affected: 5
Case mix residents reviewed: 3
Certified nursing aides trained: 3
CNA part-time work days: 3
Resident restorative therapy sessions received: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Completed restorative services training but has not provided services due to part-time floor work |
| CNA #2 | Certified Nursing Aide and Facility Van Driver | Trained to provide restorative services but does not provide them due to transport duties |
| CNA #3 | Certified Nursing Aide | Trained to provide restorative services but works on floor providing resident care without restorative services |
| Director of Nursing | Director of Nursing (DON) | Confirmed restorative therapy services were not being provided and described staffing and efforts to start services |
| Administrator | Administrator | Confirmed the facility was not providing restorative services and is working to implement them |
Inspection Report
Routine
Deficiencies: 11
Date: Apr 14, 2023
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including resident care, medication administration, safety, and food service standards.
Findings
The facility was found deficient in multiple areas including call light accessibility, privacy during wound care, medication coding errors on the Minimum Data Set, inadequate nail care, unsafe storage of sharp objects, improper storage of oxygen equipment, failure to assess dialysis fistulas promptly, medication administration errors, unsecured medications, uncovered food during transport and storage, and improper food storage and labeling practices.
Deficiencies (11)
Call lights were not within reach for 1 of 15 sampled residents, potentially affecting 22 residents.
Privacy was not maintained during wound care and medical information was visible on computers.
Medications were inaccurately coded on the Minimum Data Set for 1 of 5 sampled residents.
Nail care was not regularly provided for 2 of 15 sampled residents requiring assistance.
Scissors, razors, clippers, and nail files were not locked and stored properly for 3 of 15 sampled residents.
Oxygen tubing and cannulas were not stored properly, risking contamination for 1 of 4 sampled residents.
Dialysis fistulas and dressings were not assessed immediately upon return from dialysis for 1 of 2 sampled residents.
Medication error rate of 8% observed during medication administration for 1 of 5 sampled residents.
Resident medications were not stored in a locked medication cart for 1 of 15 sampled residents.
Food and beverages were uncovered during transport and on kitchen counters, risking contamination.
Food items in refrigerator, freezer, and dry storage were not dated or sealed; spices were old and contaminated; food handling practices were unsafe.
Report Facts
Residents sampled: 15
Residents affected by call light deficiency: 22
Medication administration opportunities observed: 25
Medication errors observed: 2
Medication error rate: 8
Residents sampled for medication error observation: 5
Residents receiving oxygen therapy: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and call light accessibility findings |
| LPN #2 | Licensed Practical Nurse | Named in wound care privacy, dialysis fistula assessment, and oxygen tubing storage findings |
| LPN #3 | Licensed Practical Nurse | Named in medication administration error finding |
| LPN #4 | Licensed Practical Nurse | Named in sharp object storage and medication hazard findings |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings including call light accessibility, wound care privacy, medication coding, dialysis assessment, oxygen storage, and medication administration |
| Dietary Manager | Dietary Manager (DM) | Named in food handling and storage findings |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in food transport and handling findings |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Named in nail care findings |
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