A list of the most recent deficiencies for Freeman Nursing and Rehab Community. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-01 | 2023-12-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-01 | 2023-12-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-01 | 2023-12-29 | 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 | 2023-12-01 | 2023-12-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-01 | 2023-12-29 | N |
| 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 | 2023-12-01 | 2023-12-29 | N |
| 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 | 2023-12-01 | 2023-12-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-01 | 2023-12-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-01 | 2023-12-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2023-12-29 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-12-01 | 2023-12-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-01 | 2023-12-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-01 | 2023-12-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-01 | 2023-12-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-01 | 2023-12-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-01 | 2023-12-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-05 | 2023-01-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-05 | 2023-01-04 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-05 | 2023-01-04 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-05 | 2023-01-04 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-12-05 | 2023-01-04 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-12-05 | 2023-01-04 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2022-12-05 | 2023-01-04 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2022-12-05 | 2023-01-04 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-12-05 | 2023-01-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-05 | 2023-01-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-05 | 2023-01-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-12-05 | 2023-01-04 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-12-05 | 2023-01-04 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-12-05 | 2023-01-04 | Y |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2022-12-05 | 2023-01-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-05 | 2023-01-04 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-02 | 2023-01-04 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-12-02 | 2023-01-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-12-02 | 2023-01-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-02 | 2023-01-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-02 | 2023-01-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-12-02 | 2023-01-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-02 | 2023-01-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-02 | 2023-01-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-02 | 2023-01-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-02 | 2023-01-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-02 | 2023-01-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-29 | 2022-10-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-29 | 2022-10-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-29 | 2022-10-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-29 | 2022-10-28 | 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 | 2022-09-29 | 2022-10-28 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-12-05 | 2022-07-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-24 | 2022-06-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-05 | 2022-05-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-05 | 2022-05-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-05 | 2022-05-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-05 | 2022-05-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-05 | 2022-05-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-05 | 2022-05-24 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-02-24 | 2022-04-01 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-24 | 2022-04-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-24 | 2022-04-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-24 | 2022-04-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-24 | 2022-04-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-24 | 2022-04-01 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-02-24 | 2022-04-01 | 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 | 2022-02-24 | 2022-04-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-24 | 2022-04-01 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-02-24 | 2022-04-01 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-02-24 | 2022-04-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-05 | 2021-09-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-05 | 2021-09-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-09-08 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2021-08-05 | 2021-09-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-10 | 2021-09-08 | N |
