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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-09 | 2023-09-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-09 | 2023-09-15 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-23 | 2023-04-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-23 | 2023-04-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-23 | 2023-04-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-23 | 2023-04-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-22 | 2022-12-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-22 | 2022-12-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-22 | 2022-12-31 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-29 | 2022-05-13 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-09 | 2022-01-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-12-10 | 2022-01-12 | 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 | 2021-12-10 | 2022-01-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-10 | 2022-01-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-10 | 2022-01-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-10 | 2022-01-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-10 | 2022-01-12 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-10 | 2022-01-12 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-09 | 2021-12-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-08-28 | 2020-01-13 | N |
| 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 | 2019-08-29 | 2019-10-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-29 | 2019-10-24 | 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 | 2019-08-29 | 2019-10-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-29 | 2019-10-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-28 | 2019-09-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-08-28 | 2019-09-11 | N |
