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Freedom Village Healthcare Center

Details

Type of Ownership For profit - Partnership
Participates in Medicare? Yes
Participates in Medicaid? Yes
Certified Beds 52
Continuing Care? No
Resident Council? Yes
Family Council? No
Multi-Home Chain? No
Located in a Hospital? No
Special Focus Facility? No

View:    Health Inspections  |  Quality Measures  |  Staffing  |  Fire Inspections

Health Inspections  

Most Recent Inspection: 03/02/2012

Date of last standard health inspection: 03/02/2012
Quality Indicator Survey No
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Health Deficiencies for this nursing home: 0
Average number of Health Deficiencies in CA: 2
Average number of Health Deficiencies in US: 3
Range of Health Deficiencies in CA: 0 - 16

Inspection, 00/03/2010

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. 00/03/2010 00/02/2011 2 Few
Keep accurate 00/03/2010 00/02/2011 Few complete and organized clinical records on each re
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/03/2010 00/02/2011 2 Few
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop and implement policies for 1) screening and training employees; and the 2) prevention 00/03/2010 00/02/2011 investigation identification
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 00/03/2010 00/02/2011 2 Few
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 00/03/2010 00/02/2011 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide medically-related social services to help each resident achieve the highest possible quality of life. 00/03/2010 00/02/2011 2 Few
Provide care by qualified persons according to each resident's written plan of care. 00/03/2010 00/02/2011 2 Few
Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. 00/03/2010 00/02/2011 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 00/03/2010 00/02/2011 2 Few
Properly care for residents needing special services 00/03/2010 00/02/2011 colostomy including: injections
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Assess in a timely manner the resident when the resident enters the nursing home. 00/03/2010 00/02/2011 2 Few
Develop a complete care plan that meets all the resident's needs 00/03/2010 00/02/2011 Few with timetables and actions that can be measured.
Allow residents the right to participate in the planning or revision of care and treatment. 00/03/2010 00/02/2011 1 Some
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that residents are fully informed and understand their health status 00/03/2010 00/02/2011 Few care and treatments.
Keep residents' personal and medical records private and confidential. 00/03/2010 00/02/2011 2 Few

Inspection, 00/02/2003

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Post nurse staffing information/data on a daily basis. 00/02/2003 00/02/2004 1 Many
Train all employees on what to do in an emergency, and carry out unannounced staff drills. 00/02/2003 00/02/2004 2 Few
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. 00/02/2003 00/02/2004 2 Many
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/02/2003 00/02/2004 2 Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 00/02/2003 00/02/2004 2 Few
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Hire a qualified dietician. 00/02/2003 00/02/2004 2 Many
Store, cook, and serve food in a safe and clean way. 00/02/2003 00/02/2004 2 Many
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 00/02/2003 00/02/2004 2 Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 00/02/2003 00/02/2004 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. 00/02/2003 00/02/2004 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 00/02/2003 00/02/2004 2 Few
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. 00/02/2003 00/02/2004 2 Few
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. 00/02/2003 00/02/2004 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure each resident receives an accurate assessment by a qualified health professional. 00/02/2003 00/02/2004 2 Few
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 00/02/2003 00/02/2004 2 Few
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. 00/02/2003 00/02/2004 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that residents are fully informed and understand their health status, care and treatments. 00/02/2003 00/02/2004 2 Few
Allow residents to self-administer drugs if determined safe. 00/02/2003 00/02/2004 2 Few

Inspection, 00/02/2002

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Post nurse staffing information/data on a daily basis. 00/02/2002 01/05/2003 1 Some
Keep accurate, complete and organized clinical records on each resident that meet professional standards. 00/02/2002 01/05/2003 2 Few
Train all employees on what to do in an emergency, and carry out unannounced staff drills. 00/02/2002 01/05/2003 2 Few
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/02/2002 01/05/2003 2 Some
Have a program that investigates, controls and keeps infection from spreading. 00/02/2002 01/05/2003 2 Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 00/02/2002 01/05/2003 2 Few
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. 00/02/2002 01/05/2003 2 Few
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Store, cook, and serve food in a safe and clean way. 00/02/2002 01/05/2003 2 Many
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 00/02/2002 01/05/2003 2 Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 00/02/2002 01/05/2003 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide medically-related social services to help each resident achieve the highest possible quality of life. 00/02/2002 01/05/2003 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/02/2002 01/05/2003 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Assess in a timely manner the resident when the resident enters the nursing home. 00/02/2002 01/05/2003 2 Few
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 00/02/2002 01/05/2003 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 00/02/2002 01/05/2003 2 Few

Inspection, 03/01/2001

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 03/01/2001 00/02/2003 2 Few
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 03/01/2001 00/02/2003 2 Some
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. 03/01/2001 00/02/2003 2 Many
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 03/01/2001 00/02/2003 2 Few
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. 03/01/2001 00/02/2003 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Assess in a timely manner the resident when the resident enters the nursing home. 03/01/2001 00/02/2003 1 Some

Nursing Home Staffing  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

National Average Average in CA Golden Living Center, Asheville
RN Staff Only1 N/A N/A 4 out of 5 stars
Total Number of Residents 86 81 37
Total, Licensed Nurse Staff Hours
per Resident per Day
16 hours 51 minutes 27 hours 36 minutes 2 hours 4 minutes
RN Hours
per Resident per Day
16 hours 3 minutes 26 hours 44 minutes 58 minutes
LPN/LVN Hours
per Resident per Day
16 hours 17 minutes 27 hours 42 minutes 1 hour 6 minutes
CNA Hours
per Resident per Day
17 hours 46 minutes 28 hours 39 minutes 3 hours 55 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.

Quality Measures  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

Long-Term Residents

Short-Term Residents

Fire Safety Inspections

Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.

Most Recent Inspection: 03/06/2012

Automatic Sprinkler Systems in all required areas Yes
Date of last standard fire safety inspection: 03/06/2012
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Fire Safety Deficiencies for this nursing home: 0
Average number of Fire Safety Deficiencies in CA: 2
Average number of Fire Safety Deficiencies in US: 2
Range of Fire Safety Deficiencies in CA: 0 - 5

Inspection, 00/06/2003

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 00/06/2003 01/08/2004 2 Few
Portable fire extinguishers. 00/06/2003 01/08/2004 2 Few
Building Construction Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Approved construction type or materials. 00/06/2003 01/08/2004 2 Few
Corridor Walls and Doors Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Corridor and hallway doors that block smoke. 00/06/2003 01/08/2004 2 Few
Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly installed electrical wiring and equipment. 00/06/2003 01/08/2004 1 Many

Inspection, 01/05/2002

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 01/05/2002 01/07/2003 2 Few
Building Construction Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Approved construction type or materials. 01/05/2002 01/07/2003 2 Some
Furnishings and Decorations Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exits that are free from obstructions and can be used at all times. 01/05/2002 01/07/2003 2 Some

Inspection, 00/07/2002

Building Service Equipment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. 00/07/2002 02/05/2002 2 Few
Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly installed electrical wiring and equipment. 00/07/2002 02/05/2002 2 Few
Exits and Egress Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exits that are accessible at all times. 00/07/2002 02/05/2002 2 Few
Fire Alarm Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly maintained smoke detectors. 00/07/2002 02/05/2002 2 Some
Smoke Compartmentation and Control Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Smoke barrier doors that can resist smoke for at least 20 minutes. 00/07/2002 02/05/2002 2 Some
Vertical Openings Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. 00/07/2002 02/05/2002 2 Few
Protected exits that allow the resident to escape the building. 00/07/2002 02/05/2002 2 Few
 

23442 El Toro Road
Lake Forest, CA 92630

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