Public Record
Freedom Village Healthcare Center
From CMS
Facility profile
- CMS overall rating
- 3 / 5
- Certified beds
- 52
- Avg. residents per day
- 39
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 73
- Inspections on file
- 9
- Last inspection
- 2025-11-26
*CMS
*CMS
*CMS
Citations
73 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0353Generalno actual harm
Inspect, test, and maintain automatic sprinkler systems.
- 0161Generalpotential for harm
Use approved construction type or materials.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0887Generalpotential for harm
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0842Generalno actual harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0761Generalpotential for harm
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.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0628Generalno actual harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0574Generalno actual harm
The resident has the right to receive notices in a format and a language he or she understands.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0842Generalno actual harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0761Generalpotential for harm
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.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0582Generalpotential for harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0578Generalpotential for harm
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.
- 0908Generalpotential for harm
Keep all essential equipment working safely.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0849Generalpotential for harm
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.
- 0813Generalpotential for harm
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0806Generalpotential for harm
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- 0803Generalno actual harm
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.
- 0801Generalpotential for harm
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.
- 0758Generalpotential for harm
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.
- 0695Generalno actual harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0345Generalno actual harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0685Generalpotential for harm
Assist a resident in gaining access to vision and hearing services.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0758Generalpotential for harm
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.
- 0761Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0553Generalpotential for harm
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0825Generalpotential for harm
Provide or get specialized rehabilitative services as required for a resident.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0004Generalno actual harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006Generalpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0015Generalno actual harm
Address subsistence needs for staff and patients.
- 0032Generalno actual harm
Provide primary/alternate means for communication.
- 0035Generalpotential for harm
Provide family notifications of emergency plan.
- 0041Generalno actual harm
Implement emergency and standby power systems.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0346Generalno actual harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0754Generalpotential for harm
Provide properly sized and located linen or trash receptacles.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0926Generalpotential for harm
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection18 deficiencies
- Inspection18 deficiencies
F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review…
Read full statement of deficiencies - View inspection reportInspection1 deficiency
- Inspection1 deficiency
F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT…
Read full statement of deficiencies - Inspection2 deficiencies
F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to follow the abuse…
Read full statement of deficiencies - View inspection reportInspection24 deficiencies
- Inspection24 deficiencies
F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review…
Read full statement of deficiencies - Inspection27 deficiencies
F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview…
Read full statement of deficiencies - View inspection reportInspection27 deficiencies
FAQ
Questions and answers
- What is Freedom Village Healthcare Center?
- Freedom Village Healthcare Center is a Medicare- and Medicaid-certified nursing home in Lake Forest, CA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 555391.
- What is the CMS rating for Freedom Village Healthcare Center?
- Freedom Village Healthcare Center has a CMS overall rating of 3 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Freedom Village Healthcare Center have?
- Freedom Village Healthcare Center is certified for 52 beds. It serves an average of 39 residents per day.
- How many citations does Freedom Village Healthcare Center have?
- Freedom Village Healthcare Center has 73 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Freedom Village Healthcare Center last inspected?
- Freedom Village Healthcare Center was last inspected on November 26, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/555391-freedom-village-healthcare-center