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Deficiency Records for Freedom Village Healthcare Center
A list of the most recent deficiencies for Freedom Village Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Freedom Village Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-12-26 | 2025-01-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-12-06 | 2024-12-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-12-06 | 2024-12-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-24 | 2024-11-17 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-10-24 | 2024-11-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-10-24 | 2024-11-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-10-24 | 2024-11-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-10-24 | 2024-11-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-10-24 | 2024-11-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-10-24 | 2024-11-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-10-24 | 2024-11-17 | N |
| 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. | Health | 2024-10-24 | 2024-11-17 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-10-24 | 2024-11-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-10-24 | 2024-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-24 | 2024-11-17 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-10-24 | 2024-11-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-10-24 | 2024-11-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-10-24 | 2024-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-24 | 2024-11-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-10-24 | 2024-11-17 | N |
| Keep all essential equipment working safely. | Health | 2024-10-24 | 2024-11-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-10-24 | 2024-11-17 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-10-24 | 2024-11-17 | Y |
| Implement a program that monitors antibiotic use. | Health | 2024-10-24 | 2024-11-17 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-29 | 2024-11-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-29 | 2024-11-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-10-29 | 2024-11-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-10-29 | 2024-11-11 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-02-10 | 2023-03-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-10 | 2023-03-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-10 | 2023-03-12 | N |
| Provide activities to meet all resident's needs. | Health | 2023-02-10 | 2023-03-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-10 | 2023-03-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-02-10 | 2023-03-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-10 | 2023-03-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-10 | 2023-03-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-10 | 2023-03-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-10 | 2023-03-12 | N |
| 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. | Health | 2023-02-10 | 2023-03-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-10 | 2023-03-12 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-02-10 | 2023-03-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-10 | 2023-03-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-02-15 | 2023-03-06 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-09-25 | 2019-10-11 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-25 | 2019-10-11 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-09-25 | 2019-10-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-25 | 2019-10-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-09-25 | 2019-10-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-25 | 2019-10-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-23 | 2019-09-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-08-23 | 2019-09-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-23 | 2019-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-23 | 2019-09-22 | N |
| Keep all essential equipment working safely. | Health | 2019-08-23 | 2019-09-22 | N |
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