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Lake Forest Village by Purehealth
3901 Montecito Drive, Denton, TX 76210 · CMS Certification Number (CCN) 455685
At a glance
- CMS overall rating
- ★★★★☆ 4 of 5
- Health inspection citations
- 12 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 3 from complaints)
- Fire safety citations
- 11
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- September 11, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★★★☆ 4 of 5 | 2.7 | 3 |
| Health inspections | ★★★☆☆ 3 of 5 | 2.8 | 2.8 |
| Staffing | ★★★★☆ 4 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★★ 5 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
| Short-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | September 11, 2025 | 9 | 8 | 1 |
| Cycle 2 | August 8, 2024 | 2 | 0 | 2 |
CMS weighted health inspection score: 59 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: 1. How to read these citations
12 health citations across 5 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
February 11, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 03/09/2026 |
September 11, 2025: 8 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/10/2025 |
| F | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/10/2025 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/10/2025 |
| E | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/10/2025 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/10/2025 |
| D | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/10/2025 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/10/2025 |
| E | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 10/10/2025 |
July 8, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 08/04/2025 |
September 7, 2023: 1 citation (Complaint + Infection control)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies | Complaint + Infection control | Deficient, Provider has date of correction Corrected 10/02/2023 |
June 22, 2023: 1 citation (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/22/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Fire safety inspections
11 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 09/11/2025 | F | K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/10/2025 |
| 09/11/2025 | F | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 10/10/2025 |
| 09/11/2025 | F | K-0291 | Install emergency lighting that can last at least 1 1/2 hours. Egress Deficiencies | Deficient, Provider has date of correction Corrected 10/10/2025 |
| 09/11/2025 | F | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 10/10/2025 |
| 08/08/2024 | F | K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 09/04/2024 |
| 08/08/2024 | F | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 09/04/2024 |
| 08/08/2024 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 09/04/2024 |
| 08/08/2024 | F | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 09/04/2024 |
| 06/22/2023 | F | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/19/2023 |
| 06/22/2023 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/19/2023 |
| 06/22/2023 | E | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/19/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.97 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.94 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.73 | Not published | Not published |
| Nurse aide hours per resident per day | 2.3 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.42 | Not published | Not published |
| RN hours per resident per day, weekends | 0.46 | Not published | Not published |
| Total nursing staff turnover (%) | 44.2 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 37.5 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Facility details
- Legal business name
- Lfv Ops Denton LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Purehealth (8 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 60
- Average residents per day
- 36.8
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- Yes
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- February 19, 1987
- County/parish
- Denton
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Owners and managers reported to CMS
15 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| LFV OPS DENTON LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| KCCJ1 HOLDINGS LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| LBEI HOLDINGS LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| OVERHEAD OPS INVESTMENTS III LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Organization | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| BELL, KEVIN | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| CAMPION, ROBERT | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | Individual | NO PERCENTAGE PROVIDED | undefined undefined, NaN |
| LFV OPS DENTON LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LEIDHOLM, THETA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MARTINEZ, FREDDIE | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LEGENDS III LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MANAGEMENT MCOA LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| PPSG CONSULTING SERVICES LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LEIDHOLM, THETA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MARTINEZ, FREDDIE | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NARREDDY, NEELIMA | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Check it yourself
- Medicare Care Compare: Lake Forest Village by Purehealth. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 25, 2026. Not a ranking or endorsement.