Deficiency Records for The Inn at Freedom Village
Updated as of April 01, 2021
This is not the most recent data for The Inn at Freedom Village. For the most recent information, click here.
A list of the most recent deficiencies for The Inn at Freedom Village. 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? |
|---|---|---|---|---|
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-02-23 | 2021-03-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-02-23 | 2021-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-23 | 2021-03-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-02-12 | 2021-03-12 | 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 | 2021-02-12 | 2021-03-12 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-02-12 | 2021-03-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-12 | 2021-03-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-09 | 2019-08-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-09 | 2019-08-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-09 | 2019-08-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-09 | 2019-08-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-09 | 2019-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-11 | 2019-08-09 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-07-11 | 2019-07-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-07-11 | 2019-07-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-06 | 2019-02-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-10 | 2018-11-16 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-09-10 | 2018-11-16 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-09-10 | 2018-10-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-07-06 | 2018-07-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-07-06 | 2018-07-25 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-03-13 | 2018-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-13 | 2018-05-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-13 | 2018-05-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-16 | 2018-04-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-03-16 | 2018-04-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-03-16 | 2018-04-16 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-03-16 | 2018-04-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-16 | 2018-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-16 | 2018-04-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-03-16 | 2018-04-16 | 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 | 2018-03-16 | 2018-04-16 | 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 | 2018-03-16 | 2018-04-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-16 | 2018-04-16 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-03-16 | 2018-04-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-03-13 | 2018-04-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-13 | 2018-04-15 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-03-13 | 2018-04-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-13 | 2018-04-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-03-13 | 2018-04-15 | N |
