Inspection visit

Health inspectionFebruary 10, 2023

FREEDOM VILLAGE HEALTHCARE CENTERCMS #55539114 citations on this visit

14 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 14 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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, medical record review, and facility P&P review, the facility failed to ensure a quarterly care conference was conducted for one of 14 final sampled residents (Resident 14). * Resident 14's last quarterly care conference was conducted on 9/20/22. The residents' care conferences were scheduled on a quarterly basis. However, there was no documentation of any other care conferences conducted for Resident 14 after 9/20/22. This posed the risk of violating the rights of Resident 14 and/or responsible party to participate in choosing the treatment options and making the decisions in care planning. Findings: Review of the facility's P&P titled Care Plan Meetings dated 11/2022 showed the Social Worker will schedule the care plan meetings. The resident, resident's family, and/or resident's legal representative/guardian or surrogate are encouraged to attend the scheduled quarterly care plan meetings. Medical record review for Resident 14 was initiated on 2/8/23. Resident 14 was admitted on [DATE], and readmitted on [DATE]. Review of Resident 14's annual MDS dated [DATE], showed Resident 14 was cognitively intact. On 2/8/23 at 0951 hours, an interview was conducted with Resident 14. Resident 14 was asked when she was last offered a care conference and stated, I don't know. On 2/8/23 at 1456 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified Resident 14's care conferences were conducted on 3/18, 6/16, and 9/20/22, as shown in Resident 14's medical record. The SSD stated for the long-term care residents, the care conferences were scheduled quarterly, annually, significant change of condition, and as needed. The SSD confirmed Resident 14 did not have a scheduled quarterly care conference after 9/20/22, and should have had one in December 2022. On 2/8/23 at 1530 hours, an interview was conducted with the SSD. The SSD verified Resident 14 did not have a quarterly care conference for December of 2022, and it was missed. The SSD stated the care conferences were important for the communication in the resident's care updates and care choices with treatments. On 2/10/23 at 0748 hours, an interview was conducted with the DON. The DON verified the above (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 33 Event ID: 555391 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0553 findings and stated the care conference should be scheduled and conducted within seven days upon admission, quarterly, annually, during a significant change of condition, and as needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 2 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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, the facility failed to ensure one nonsampled resident (Resident 736) who could not safely self-administer medications had the medication at the bedside. This failure had the potential for Resident 736 to administer medications inaccurately. Residents Affected - Few Findings: Review of the facility's P&P titled Omnicare 2.1 Self Administering Medications revised 5/2010 showed the facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and appropriate. On 2/7/23 at 0949 hours, two packets of unopened hydrocortisone cream 1% (a medicated cream used to reduce inflammation of the skin) were seen on the bedside table of Resident 736. When asked what the medication cream was for, Resident 736 stated she did not know why it was there. On 2/7/23 at 1014 hours, a concurrent interview and observation was conducted with LVN 1. When asked about the packets of hydrocortisone cream 1% on Resident 736's bedside table, LVN 1 stated it should have not been left in the room. LVN 1 stated there was no order for the hydrocortisone cream 1%. On 2/8/23 at 0853 hours, an interview was conducted with RN 1. RN 1 stated the hydrocortisone cream 1% was to be stored in the treatment cart. RN 1 further stated the expectation was to discard the creams after use and would not leave them at the bedside. On 2/10/23 at 0924 hours, an interview was conducted with the DON. When asked where the medications should be kept, the DON stated they should be kept in the medication cart, medication room, or treatment cart for ointments and supplies. The DON stated the medications should not be kept at bedside if the resident was not able to administer their own medications; if they wanted to self-administer, then they would have to be cognitively and physically able; other than that, the medications should not be kept at the bedside. When asked how the residents were evaluated to self-administer medication, the DON stated there was a checklist which would be completed if the resident wished to self-administer their medications. When asked if it was appropriate to keep medications at the bedside if the resident was evaluated as not able to self-administer medications, the DON stated no. The DON stated the hydrocortisone cream 1% was considered a medication. Medical record review of Resident 736 was initiated on 2/10/23. Resident 736 was admitted to the facility on [DATE]. Review of Resident 736's History and Physical Examination dated 2/7/23, showed Resident 736 did not have capacity to understand and make decisions. Review of Resident 736's Order Summary Report failed to show an order for hydrocortisone cream 1%. Review of Resident 736's evaluations for Self-Administration of Medication dated 2/6/23, showed Resident 736 was not a candidate for safe self-administration of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 3 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents) was notified of the discharge for one of three closed record sampled residents (Resident 28). This failure had the potential of not providing Resident 74 with access to an advocate who could inform them of their options and rights related to discharge. Findings: Closed medical record review for Resident 28 was initiated on 2/9/23. Resident 28 was admitted to the facility on [DATE], and discharged on 2/1/23. Review of the facility's document titled Notice of Transfer and Discharge with effective discharge date of 2/1/23, failed to show the State Long-Term Care Ombudsman was notified of Resident 28's discharge to home. On 2/9/23 at 1245 hours, an interview and concurrent facility document review was conducted with the SSD. The SSD was asked if the facility had notified the Long-Term Care Ombudsman of Resident 28's discharge to home on 2/1/23. The SSD checked the facility's Notice of Transfer and Discharge document and noted the box for notifying the Long-Term Care Ombudsman was blank. The SSD stated the Long-Term Care Ombudsman was not notified and the Notice of Discharge document was not sent because the SSD was on medical leave at that time, and no one else had notified the ombudsman. The SSD stated the facility notified the Long-Term Care Ombudsman once the resident was discharged from the facility on a routine basis. The SSD further stated the importance of notifying the Long-Term Care Ombudsman was for the residents to have an advocate for information regarding their discharge, rights, and options for appeal processes. On 2/10/23 at 0750 hours, an interview was conducted with the DON. The DON verified the above findings and stated the Long-Term Care Ombudsman should have been notified for the resident's discharge or transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 4 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of 14 final sampled residents (Resident 2) and one nonsampled resident (Resident 11). Residents Affected - Few * The facility failed to provide activities for Residents 2 and 11 to meet the resident's identified interests. The facility failed to ensure the TV remote controls were provided for Residents 2 and 11. This had the potential for the residents to experience feelings of social isolation and frustration. Findings: 1. On 2/7/23 at 0948 hours, Resident 2 was observed in bed and awake. There was no in-room sensory stimulation observed. The TV was observed turned off. On 2/8/23 at 0853 hours, Resident 2 was observed in bed and awake. Resident 2 was observed staring at the window. There was no in-room sensory stimulation observed. The TV was observed turned off. When asked if she wanted to watch TV, Resident 2 nodded her head and said yes. On 2/8/23 at 0856 hours, a staff was observed going into the resident's room, but was observed going out of the room immediately. The staff was observed not talking to the resident or turning the TV on. Medical record review for Resident 2 was initiated on 2/7/23. Resident was readmitted to the facility on [DATE]. Review of Resident 2's History and Physical examination dated 12/21/22, showed Resident 2 could make needs known but could not make medical decisions. Review of Resident 2's Activity Department assessment dated [DATE], showed Resident 2's activity preferences included arts and crafts, cards, puzzles, games, exercise, sports, movies, and television. Review of Resident 2's Activity Quarterly assessment dated [DATE], showed Resident 2 participated with 1:1 room activities of interest and enjoyed group activities. The assessment also showed Resident 2 interacted and engaged in conversation with the staff and residents. Review of Resident 2's plan of care showed a care plan problem dated 2/7/23, addressing activity participation. The interventions/tasks included group activities on hold, in-room visits provided, activity staff provided contact/room visits as needed. Review of Resident 2's Activity Participation Log (Group/ Room Visits) for January 2023 showed Resident 2 was provided activities on 1/1, 1/4, 1/6, 1/9, 1/10, 1/11, 1/15, 1/18, and 1/21/23. The log showed the independent room activities provided to Resident 2 were reading, watching TV, and sitting outside/patio. There was a total of nine days when Resident 2 was provided activities in January 2023. On 2/8/23 at 1442 hours, an interview and concurrent medical record review for Resident 2 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 5 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm conducted with the Activity Director. The Activity Director verified the above findings. When asked what activities were provided to Resident 2, the Activities Director stated Resident 2 liked entertainment, exercises, watching classic movies, and listening to classical music on TV. When asked how often they provided one-to-one room visits, the Activity Director stated the activity staff provided one-to-one room visits at least three times per week. Residents Affected - Few On 2/8/23 at 1515 hours, an observation for Resident 2 and concurrent interview was conducted with the Activity Director. Resident 2 was observed in bed and awake. Resident 2 was observed staring at the window. There was no in-room sensory stimulation observed. The TV was observed turned off. The Activity Director tried to turn the television on but could not find the remote control. The Activity Director stated she would file a work order to the maintenance department for a TV remote control. 2. On 2/7/23 at 0945 hours, Resident 11 was observed in bed and awake. There was no in-room sensory stimulation observed. The TV was observed turned off. On 2/7/23 at 0951 hours, Resident 11 was observed getting out of bed and walking out of the room. CNA 4 was observed assisting Resident 11 back to bed. On 2/7/23 at 0957 hours, after assisting Resident 11 back to bed, CNA 4 was observed asking Resident 11 if she wanted the TV on, and Resident 11 answered yes. CNA 4 was observed looking for the remote control but could not find it. Medical record review for Resident 11 was initiated on 2/7/23. Resident was readmitted to the facility on [DATE]. Review of Resident 11's History and Physical Examination dated 11/8/22, showed Resident 11 could make needs known but could not make medical decisions. Review of Resident 11's Activity Quarterly assessment dated [DATE], showed Resident 11 enjoyed group and independent activities. Review of Resident 11's Activity Department assessment dated [DATE], showed Resident 11's activity preferences included arts and crafts, cards, puzzles, games, exercise, sports, movies, and television. Review of Resident 11's plan of care showed a care plan problem dated 12/6/22, addressing activity participation. The interventions/tasks included group activities on hold, in-room visits provided, activity staff provided contact/room visits as needed, and socialize with resident three to five times weekly. Review of Resident 11's Activity Participation Log (Group/ Room Visits) for January 2023 showed Resident 11 was provided activities on 1/1, 1/6, 1/8, 1/9, 1/11, 1/13, 1/16, and 1/19/23. The log showed the independent room activities provided to Resident 11 were watching TV and sitting outside/patio. There was a total of eight days when Resident 2 was provided activities in January 2023. On 2/8/23 at 1500 hours, an interview and concurrent medical record review for Resident 11 was conducted with the Activity Director. The Activity Director verified the above findings. On 2/8/23 at 1516 hours, an observation for Resident 11 and concurrent interview was conducted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 6 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm the Activity Director. Resident 11 was observed sitting in the wheelchair and awake. There was no in-room sensory stimulation observed. The TV was observed turned off. The Activity Director tried to turn the TV on but could not find the remote control. The Activity Director stated she would file a work order to the maintenance department for a TV remote control. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 7 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of 14 final sampled residents (Resident 10) on hospice services attained and maintained their highest practicable well-being. Residents Affected - Few * The facility failed to communicate with the hospice agency regarding the RN/ LVN and CHHA visitation when Resident 10 was in isolation for Covid-19. This had the potential of a delay in hospice care regarding changes in Resident 10's condition. Findings: Medical record review for Resident 10 was initiated on 2/7/23. Resident 10 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 7/20/22, for Resident 10 to be admitted to hospice services under routine level of care. Review of the hospice calendar for January and February 2023 showed the RN/LVN was scheduled to visit two times per week, and the CHHA was scheduled to visit three times per week. Further review of the hospice calendar showed the RN/LVN was scheduled to visit on 1/2, 1/6, 1/9, 1/13, 1/16, 1/20, 1/23, 1/27, 1/30, 2/3, 2/6, 2/10, 2/13, 2/17, 2/20, 2/24 and 2/27/23. Review of the Hospice Visit Summary Log showed the RN/LVN visited Resident 10 on 1/2, 1/6, 1/13, 1/16, 1/20, 1/23, 1/27, and 2/6/23. In addition, the summary log dated 1/2/22, showed Resident 10 was in isolation for Covid-19. Further review of the log showed the RN/LVN missed to visit Resident 10 on 1/9/23. Review of the CHHA Sign-In Form for January 2023 showed the CHHA visited Resident 10 on 1/12, 1/16, 1/18, 1/19, 1/24, 1/25, 1/26, and 1/31/23. Further review of the form showed the CHHA failed to visit Resident 10 from 1/1 to 1/11/23. Review of the CHHA Sign-In Form for February 2023 showed a blank form. On 2/9/23 at 0920 hours, an interview and concurrent medical record review for Resident 10 was conducted with RN 1. When asked about the RN/LVN and CHHA visits, RN 1 stated the RN/LVN was scheduled to visit two times per week and the CHHA was scheduled to visit three times per week as per the hospice calendar. When asked why there were missing RN/LVN and CHHA visits, RN 1 he had to ask the DON about it. On 2/9/23 at 0922 hours, an interview and concurrent medical record review for Resident 10 was conducted with the DON, with the SSD and RN 1 present. The DON and SSD verified the findings. When asked why there were missing the RN/LVN and CHHA visits, the DON stated because Resident 10 was in isolation for Covid-19. When asked if they stopped the hospice staff visitation and services when Resident 10 had Covid-19, the DON answered no. The SSD stated she would follow-up with the hospice agency. On 2/10/23 at 1020 hours, a follow-up interview was conducted with the DON. The DON stated the SSD had followed up with the hospice agency and it was the hospice agency's policy to stop sending their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 8 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete hospice staff to the facility because of Covid-19. When asked for documentation of when the hospice agency communicated to the facility regarding their policy, the DON could not find any documentation. When asked if the facility communicated with the hospice agency regarding their RN/LVN and CHHA not providing visitations when Resident 10 was in isolation for Covid-19, the DON could not locate any documentation. When asked if they communicated with the hospice agency regarding the missed visits, the DON stated the hospice staff should have signed in when they visited Resident 10. Event ID: Facility ID: 555391 If continuation sheet Page 9 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Assist a resident in gaining access to vision and hearing services. 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 document review, the facility failed to ensure one of 14 final sampled residents (Resident 10) who required hearing aids received proper treatment and assistive device to maintain her hearing abilities. Residents Affected - Few * The facility failed to ensure Resident 10's hearing aids were applied as ordered by the physician. This had the potential for the resident's communication to be impaired by not being to hear conversations clearly. Findings: On 2/7/23 at 1008 hours, during the initial tour of the facility, Resident 10 was observed awake in bed. When Resident 10 was greeted, she did not respond but cupped her hand behind her ear and moved her head closer. When asked if she had hearing aids on or needed her hearing aids on, Resident 10 answered, it would probably make it better. Medical record review for Resident 10 was initiated on 2/7/23. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's MDS dated [DATE], showed Resident 19 was able to make herself understood and able to understands others. Review of Resident 10's Monarch Physician H&P examination and Progress Note dated 2/11/23, showed Resident 10 was hard of hearing. Review of Resident 10's Order Summary Report showed a physician's order dated 6/22/2020, to apply the left and right hearing aids every shift. Review of Resident 10's plan of care showed a care plan problem addressing the risk for communication problem related to hearing loss. The interventions/tasks included to assist with hearing aide storage and application daily. On 2/8/23 at 0851 hours, Resident 10 was observed awake in bed. When greeted, Resident 10 stated she did not have her hearing aids on. On 2/9/23 at 0835 hours, Resident 10 was observed awake in bed. Resident 10 stated she did not have hearing aids on and it would be nice if I can hear better. On 2/9/23 at 0839 hours, an observation for Resident 10 and concurrent interview was conducted with CNA 5. CNA 5 verified Resident 10 did not have her hearing aids on. CNA 5 stated she offered Resident 10 to put on her hearing aids this morning, but Resident 10 refused. When Resident 10 was asked if she wanted her hearing aids on, Resident 10 answered yes. CNA 5 was observed applying Resident 10's hearing aids to both ears. Resident 10 smiled and stated, my hearing is better. On 2/9/23 at 1420 hours, an interview and concurrent facility document and medical record review for Resident 10 was conducted with LVN 2. LVN 2 verified the above findings. When asked if Resident 10 had refused to have her hearing aids applied, LVN 2 answered no. LVN 2 verified there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 10 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete documentation to show Resident 10 refused to have her hearing aids applied. When asked how they monitored when Resident 10 had her hearing aids applied, LVN 2 answered she checked if the resident's hearing aids applied when she went to the room and passed medications. LVN 2 showed the facility's document titled Hearing Aide Log showing the licensed staff initialed when the residents' hearing aids were taken in and out of the medication cart. LVN 2 verified there was no documentation to show Resident 10 was monitored when her hearing aids were applied. Event ID: Facility ID: 555391 If continuation sheet Page 11 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, the facility failed to ensure the necessary care and services related to pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore to promote wound healing) were provided to one of 14 final sampled residents (Resident 17). Residents Affected - Few * The facility failed to ensure the low air loss mattress setting was consistently monitored to ensure the appropriate settings of the low air loss mattress for Resident 17. This failure posed the risk for complications and delayed wound healing. Findings: Review of the facility's P&P titled Skin Integrity/Prevention of Pressure Injuries revised 11/16/22, showed the policy is to identify and reduce risk factors for the development of pressure injuries. The treatment nurse and Medical practitioner will review the interventions and treatment for effectiveness on an on-going basis. Medical Record Review for Resident 17 was initiated on 2/9/23. Resident 17 was admitted to the facility on [DATE]. Reviw of Resident 17's plan of care showed a care plan problem initiated on 11/2/22, addressing the potential for pressure ulcer development related to impaired mobility. The care plan problem included intervention for a LAL mattreess every shift for skin management. Review of Resident 17's MDS dated [DATE], showed Resident 17 was admitted with a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure injury. On 2/8/23 at 1014 hours, Resident 17 was observed laying on a LAL mattress. The LAL mattress was turned on and set at 150 pounds. On 2/9/23 at 1441 hours, an observation and concurrent interview was conducted with Resident 17. Resident 17 was observed laying on a LAL mattress. The LAL mattress was turned on and set at 150 pounds. Review of Resident 17's Order Summary Report dated 2/7/23, showed a physician's order dated 11/4/22, for a LAL mattress every shift for skin management. On 2/10/23 at 0905 hours, a concurrent observation and interview was conducted with RN 1 and Resident 17. Resident 17 was observed with the LAL mattress turned on and set at 150 pounds. When RN 1 was asked how he knew if the setting was correct, RN 1 stated the weight setting should be based on Resident 17's weight. Resident 17 stated the staff weighed her at the beginning of the month and her most recent weight was 110 pounds. RN 1 verified Resident 17's weight was 110 pounds. RN 1 stated the LAL mattress settings needed to be adjusted down to 120 pounds since the next setting from 120 pounds was 80 pounds. On 2/10/23 at 1041 hours, a follow-up interview was conducted with RN 1. RN 1 stated the initial setting was set by the person who installed it from the medical equipment company. RN 1 stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 12 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm weight should have been adjusted when it was installed. RN 1 also stated the charge nurse may adjust the LAL mattress setting; however, the treatment nurses would check if the LAL mattress was set at the correct setting. When asked why it was important for the LAL mattress to be set at the correct setting, RN 1 stated it was important for the healing of wounds and to prevent pressure injuries. RN 1 further stated if the LAL mattress was not inflated properly, it could make the wounds worse. Residents Affected - Few On 2/10/23 at 1115 hours, an interview was conducted with the DON and Administrator. When asked regarding the use of the LAL mattress and the expectations when a resident using a LAL mattress, the DON stated it was used for the residents who were high risk for pressure injuries and most of them were with wounds. The Administrator stated if the setting was not set correctly for a long period of time, there was a potential of not providing the maximum potential benefit to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 13 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary respiratory care and services for one of 14 final sampled residents (Resident 538). Residents Affected - Few * The facility failed to ensure Resident 538's nasal cannula tubing (medical device use to deliver supplemental oxygen) was dated. This had the potential for increased risks of infection. Findings: Medical record review for Resident 538 was initiated on 2/7/23. Resident 538 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). Review of the Order Summary Report showed a physician's order dated 1/31/23, to provide oxygen at two liters per minute via nasal cannula every shift and change oxygen tubing and humidifier every Sunday. On 2/7/23 at 1009 hours, during the initial tour of the facility, an observation of Resident 538 was conducted. Resident 538 was observed in bed receiving oxygen via nasal cannula at two liters per minute. The nasal cannula tubing was observed undated. On 2/7/23 at 1433 hours, an observation and concurrent interview was conducted with CNA 1. Resident 538 was observed in bed receiving oxygen via nasal cannula at two liters per minute. The nasal cannula tubing was observed undated. CNA 1 stated Resident 538 used the nasal cannula. On 2/7/23 at 1441 hours, an observation and concurrent interview was conducted with LVN 1. Resident 538 was observed in bed receiving oxygen via nasal cannula at two liters per minute. The nasal cannula tubing was again observed undated. LVN 1 verified and acknowledged the above findings. LVN 1 further stated Resident 538 was on continuous oxygen therapy, and the nasal cannula tubing should have been dated for infection control reasons. On 2/8/23 at 1044 hours, an interview was conducted with the DSD/IP. The DSD/IP acknowledged the above findings and further stated it should have been dated for infection control reasons. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 14 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 14 final sampled residents (Resident 12) and two nonsampled residents (Residents 7 and 18). * Resident 18's hydrocodone-acetaminophen (a narcotic pain medication) Controlled Drug Record documentation did not match Resident 18's MAR. This failure posed the risk of diversion of the controlled medication. * Resident 12's chewable aspirin medication (medication used to lower the chance of heart attack) was administered without the instructions for the resident to chew, and the resident swallowed the aspirin tablet. This posed the risk of decreased absorption of Resident 12's medication. * Resident 7's ferrous sulfate (iron supplement) and calcium (calcium supplement) were administered at the same time. This posed the risk of decreased absorption of Resident 7's ferrous sulfate. Findings: Review of the facility's P&P titled Medication Administration revised date 11/16/22, showed the following: - During the medication administration, the Licensed Nurse should take all measures required by the facility's policy and applicable law to document the administration of controlled substances in accordance with applicable law and provide the resident with any necessary instructions (e.g., rotating transdermal patch sites, providing medication with fluids or foods, shaking medications prior to pouring). - After the medication administration, the Licensed Nurse should take all measures by the facility's policy and applicable law to document the necessary medication administration/treatment (e.g., when medications are opened, when medications are given, injection site of the medication, if medications are refused, PRN medications, application site) on appropriate forms. 1. On 2/7/23 at 1120 hours, during the inspection of Medication Cart 1, the Controlled Drug Records were reviewed with LVN 1. Resident 18's Controlled Drug Record for hydrocodone-acetaminophen was reviewed with LVN 1. The Controlled Drug Record showed Resident 18 was administered hydrocodone-acetaminophen 7.5 mg-325 mg one tablet on 2/6/23 at 2100 hours, for pain. Resident 18's MAR for February 2023 was reviewed with LVN 1. Resident 18's MAR did not show an administration documentation of Resident 18's hydrocodone-acetaminophen on 2/6/23 at 2100 hours. LVN 1 verified Resident 18's Controlled Drug Record for hydrocodone-acetaminophen did not match Resident 18's MAR for February 2023. Medical record review of Resident 18 was initiated on 2/7/23. Resident 18 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 15 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 18's Order Summary Report showed a physician's order date 1/9/23, to administer hydrocodone-acetaminophen 7.5 mg-325 mg one tablet by mouth every four hours as needed for moderate to severe pain; and a physician's order dated 1/18/23, to administer hydrocodone-acetaminophen 7.5 mg-325 mg one tablet by mouth every day shift one hour prior to therapy. On 2/9/23 at 1309 hours, an interview was conducted with the DON. When asked regarding the controlled drug documentation, the DON stated the nurse should sign the Controlled Drug Record and MAR right away when the controlled drug was administered. 2. On 2/7/23 at 0835 hours, a medication administration observation for Resident 12 was conducted with LVN 1. LVN 1 prepared and administered Resident 12's medications. LVN 1 was observed administering Resident 12's chewable aspirin by mouth using a spoon and Resident 12 swallowed the chewable aspirin tablet with a sip of water. Medical record review for Resident 12 was initiated on 2/7/23. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed a physician's order dated 8/19/22, to administer aspirin chewable 81 mg one tablet by mouth one time a day. On 2/7/23 at 1600 hours, an interview was conducted with LVN 1. When asked if Resident 12 chewed her aspirin, LVN 1 stated Resident 12 swallowed her aspirin tablet. LVN 1 verified she did not instruct Resident 12 to chew the aspirin medication. LVN 1 acknowledged this could decrease the absorption of the medication. 3. On 2/8/23 at 0940 hours, a medication administration observation for Resident 7 was conducted with LVN 1. LVN 1 prepared and administered Resident 7's medications. LVN 1 was observed administering Resident 7's ferrous sulfate and calcium at the same time. Review of Lexicomp (clinical drug resource) guide updated on 1/28/23, showed antacids may decrease the absorption of iron preparation. Consider separating the doses of oral iron and antacids in the patients who require chronic use of both agents and monitor for reduced iron efficacy. Medical record review for Resident 7 was initiated on 2/8/23. Resident 7 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 7's Order Summary Report showed a physician's order dated 4/8/22, to administer calcium tablet 600 mg by mouth one time a day for supplement. Review of Resident 7's MAR for February 2023 showed an order dated 10/22/22, to administer ferrous sulfate 325 mg one tablet by mouth one time a day for supplement. Review of Resident 7's MAR for February 2023 showed the ferrous sulfate and calcium tablet were to be administered daily at 0900 hours. On 2/8/23 at 1110 hours, an interview was conducted with LVN 1. When asked if Resident 7's ferrous sulfate and calcium supplements were administered at the same time, LVN 1 stated Resident 7's ferrous sulfate and calcium supplements were given at the same time. LVN 1 acknowledged calcium could decrease the absorption of ferrous sulfate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 16 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 537's medical record was initiated on 2/7/23. Resident 537 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder among others. Review of the Order Summary Report showed an order for mirtazapine tablet 15 mg one tablet by mouth at bedtime for depression manifested by poor oral intake. Further review of the medical record showed to monitor episodes of depression as evidenced by eating less than 50% of meals served every shift. Review of Resident 537's eMAR for the month of February 2023, showed the monitoring of the behavior every shift. Further review of the medical record showed the dates from 2/1/23 to 2/2/23, were marked 0. Review of Resident 537's medical record titled Follow Up Question Report from 2/1/23 to 2/9/23, showed Resident 537's intakes on 2/2/23 at 0905 hours, 2/2/23 at 1926 hours, 2/6/23 at 1410 hours, 2/7/23 at 1043 hours, and 2/7/23 at 1943 hours, were 26% - 50%. On 2/9/23 at 0946 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated Resident 537 was on antidepressant medication for consuming less than 50% meal intake and Resident 537 had episodes of less than 50% meal intake when first admitted to the facility. When asked what the 0 documentation in eMAR for Resident 537's mirtazapine behavior monitoring meant, LVN 3 stated Resident 537 ate more than 50% of his meals. LVN 3 was informed of the above findings and further stated the documentation should be the same in the eMAR and meal intake record. On 2/9/23 at 1005 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON further stated the documentation should be accurate for to provide proper interventions for Resident 537. Based on interview, medical record review, and facility P&P review, the facility failed to ensure four of 14 final sampled residents (Residents 2, 21, 30, and 537) were free from unnecessary psychotropic medications (medication that affects the brain activity). * The facility failed to provide the physician's documentation to extend Resident 30's Xanax medication (psychotropic medication) after 14 days of PRN use and the facility failed to provide a stop date on Resident 30's PRN Xanax ordered on 1/29/23. * The facility failed to provide the non-pharmacological interventions to Resident 21's depression, anxiety, and poor intakes to minimize the use of alprazolam, mirtazapine, and escitalopram medications (psychotropic medications). * The facility failed to accurately document Resident 21's monthly behavior tracking for mirtazapine use. * The facility failed to provide the non-pharmacological interventions to Resident 2's depression to minimize the citalopram use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 17 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure Resident 537's episodes of behaviors for the use of mirtazapine (antidepressant medication) were accurately documented in the eMAR. These failures had the potential for the physician to not have the necessary information and the residents to receive the unnecessary medications. Residents Affected - Few Findings: Review of the facility's P&P titled Psychopharmacologic medication Use revised 11/31/11, showed the facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other applicable law relating to the use of psychopharmacologic medications including gradual dose reduction. 1. Review of Resident 30's medical record was initiated on 2/8/23. Resident 30 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 30's MAR for January 2023 showed an order to administer Xanax 0.25 mg by mouth every eight hours as needed for anxiety for 14 days, with the start date of 1/2/23, and end date of 1/16/23. Review of Resident 30's Order Summary Report showed a physician's order dated 1/29/23, to administer Xanax 0.25 mg one tablet by mouth every eight hours as needed for anxiety manifested by verbalization of anxiousness. Review of Resident 30's medical record failed to show the physician's documentation to extend the PRN Xanax use beyond 14 days and for the PRN Xanax order dated 1/29/23, without a stop date. The facility was unable to provide the physician's documentation. On 2/9/23 at 1309 hours, an interview was conducted with the DON. When asked regarding the PRN antianxiety medications, the DON stated the PRN antianxiety medications should only be used for 14 days and the physician should have supporting documentation if the PRN antianxiety medication was extended for more than 14 days. 2. Review of Resident 21's medical record was initiated on 2/8/23. Resident 21 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 21's Order Summary Report showed the following: - a physician's order dated 11/30/22, to administer alprazolam (Xanax) 0.25 mg one tablet by mouth on time a day for anxiety manifested by inconsolable screaming, yelling, constant request for attention; - a physician's order dated 12/8/22, to administer escitalopram oxalate five mg one tablet by mouth one time a day for depression manifested by verbalization of sadness; and - a physician's order dated 1/17/23, to administer mirtazapine 15 mg one tablet at bedtime for depression manifested by poor oral intake less than 50%. a. Medical record review of Resident 21's MAR for January 2023 showed for the use of escitalopram (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 18 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication, to monitor for episodes of depression manifested by verbalization of sadness every shift. Resident 21 had one episode depression on 1/24/23, evening shift. Medical record review of Resident 21's MAR for January 2023 showed for the use of Xanax medication, to monitor for episodes of anxiety manifested by inconsolable screaming, yelling, constant request for attention, calling out inconsolable repetitive every shift. Resident 21 had the following anxiety episodes: - one episode on 1/10/23, evening shift; - one episode on 1/11/23, evening shift; - one episode on 1/12/23, morning shift; - three episodes on 1/28/23, morning shift; and - five episodes on 1/31/23, morning shift. Review of Resident 21's MAR for January 2023 showed the monitoring for the % (percentage) of poor oral intake three times a day for breakfast, lunch, and dinner for the use of Remeron (mirtazapine) medication. Resident 21 had the following intakes: - 10% for dinner on 1/17/23; - zero % for breakfast and 25% for dinner on 1/18/23; - 25% for breakfast and 25% for lunch on 1/20/23; - 25% for breakfast, lunch, and dinner on 1/22/23; - 25% for breakfast, lunch, and dinner on 1/23/23; - 25% for breakfast, lunch, and dinner on 1/24/23; and - 25% for breakfast, lunch, and dinner on 1/25/23. Review of Resident 21's MAR for February 2023 showed for the use of Xanax medication, to monitor for episodes of anxiety manifested by inconsolable screaming, yelling, constant request for attention, calling out, inconsolable repetitive every shift. Resident 21 had the following anxiety episodes: : - six episodes in the morning shift and one episode in the evening shift on 2/4/23, and - five episodes in the morning shift on 2/6/23. Review of Resident 21's MAR for February 2023 showed to monitor for poor oral intake three times a day breakfast-lunch-dinner for the use of Remeron (mirtazapine). The document showed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 19 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 - 20% for lunch on 2/1/23, Level of Harm - Minimal harm or potential for actual harm - 25% for breakfast on 2/3/23, and - 25% for breakfast on 2/5/23. Residents Affected - Few Review of Resident 21's medical record did not show documentation of the non-pharmacological interventions for Resident 21's anxiety, depression, and poor intake to minimize the use of alprazolam, escitalopram, and mirtazapine medications. On 2/9/23 at 1226 hours, a concurrent interview and medical record review was conducted with LVN 2. When asked if the non-pharmacological interventions were provided for Resident 21's anxiety, depression, and poor intake, LVN 2 stated there were no documentation of non-pharmacological interventions provided for Resident 21's anxiety, depression, and poor intake. b. Medical record review of Resident 21's Order Summary Report showed a physician's order dated 1/17/23, to monitor Resident 21 for poor oral intake three times a day for breakfast, lunch, and dinner for the use of mirtazapine. Medical record review of Resident 21's MAR for January 2023 showed the monitoring for poor oral intake three times a day for breakfast, lunch, and dinner for the use of Remeron (mirtazapine). The MAR showed the resident's poor intake episodes as follows: - one episode on 1/17/23, - two episodes on 1/18/23, - two episodes on 1/20/23, - three times on 1/22/23, - three times on 1/23/23, - three times on 1/24/23, and - three times on 1/25/23. Medical record review of Resident 21's Psychotropic Tracking Record showed a behavior of poor oral intake less than 50% of each meal. The behavior tracking showed a total of zero episode in January. On 2/9/23 at 1240 hours, a concurrent interview and medical record review was conducted with the ADON. When asked if the non-pharmacological interventions were provided for Resident 21's poor intake, the ADON stated no documentation of non-pharmacological interventions for the resident's poor intake. The ADON acknowledged Resident 21's MAR for monitoring of episodes of meal intake less than 50% and Psychotropic Tracking Record for January 2023 did not match. 3. Review of Resident 2's medical record was initiated on 2/9/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 20 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 2's Order Summary Report showed a physician's order dated 12/2/22, to administer citalopram 10 mg one tablet by mouth one time a day for depression manifested by withdrawal from social activities. Review of Resident 2's medical record did not show the non-pharmacological interventions was provided for the resident's depression to minimize the use of citalopram medication. On 2/9/23 at 1530 hours, a concurrent interview and record review of Resident 2's medical record was conducted with LVN 2. LVN 2 verified there was no documentation of non-pharmacological interventions for the use of Resident 2's citalopram medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 21 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to store the medication and supplies according to the manufacturer's recommendations. * Medication Cart 2 had Resident 16's Novolin R FlexPen insulin injection (medication used to lower blood sugar) with an opened date of 12/29/22, and labeled to expire on 1/27/23. This failure had the potential for the administration of deteriorated medication. * Medication Cart 3 had the expired IV supplies. This had the potential for use of expired supplies. * The facility failed to store the A&D ointment securely and inaccessible by the residents and visitors. This had the potential for unauthorized access to the medication. Findings: Review of the facility's P&P titled Storge and Expiration of Medications, Biologicals, Syringes and Needles revised 4/1/22, showed the facility should ensure that medications and biologicals for expired or discharged residents are store separately, away from use, until destroyed or returned to provider and facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law. 1. On 2/7/23 at 1206 hours, a medication administration observation for Resident 16 was conducted with LVN 2. LVN 2 checked Resident 16's blood sugar prior to giving insulin. LVN 2 checked Resident 16's physician's order and stated Resident 16 needed seven units of insulin medication. LVN 2 found Resident 16's Novolin R FlexPen insulin was expired in Medication Cart 2 while preparing Resident 16's insulin medication. LVN 2 verified Resident 16's Novolin R FlexPen was opened on 12/29/22, and labeled to expire 1/27/23. LVN 2 stated Resident 16 expired Novolin R FlexPen medication will be placed in Medication room [ROOM NUMBER] for disposal. Review of Lexicomp (clinical drug resource) guide updated 12/12/22, showed to store Novolin R FlexPen unopened (not in use) pens in the refrigerator between two degrees Celsius and eight degrees Celsius (36 degrees Fahrenheit to 40 degrees Fahrenheit) until product expiration date or at room temperature (less than 30 degrees Celsius (less than 86 degrees Fahrenheit) for less than or equal to 28 days; store in use (opened) pens at room temperature (less than 30 degrees Celsius (less than 86 degrees Fahrenheit) for less than or equal to 28 days. Review of Resident 16's medical record was initiated on 2/7/23. Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 16's Order Summary Report showed a physician's order dated 1/13/22, showed to administer Novolin R solution 100 units per ml inject subcutaneously (between the skin and muscle) per sliding scale (a dose of insulin based on blood sugar level before meal). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 22 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/9/23 at 1309 hours, an interview was conducted with the DON. When asked regarding the expired medication in the medication cart, the DON stated the expired medications should be disposed and reordered from the pharmacy. 2. On 2/7/23 at 1506 hours, Medication Cart 3 inspection was conducted with RN 1. Medication 3 Cart had the following expired IV supplies: - 11 pieces of SafetyGlide Needles (needle used to access a vein) had expired on 1/21, - one piece of Integra syringe with needle had expired on 6/17, - four pieces of Max Plus needleless connector (plastic cap used to access an IV) had expired on 1/19/23, - one piece of Max Plus needleless connector had expired on 1/22/23, - one piece of Max Plus needless connector had expired on 2/6/23, - one piece of SorbaView Shield (type of dressing) had expired on 4/22, - one piece of Tagaderm (type of dressing) had expired on 9/19, - one piece of Flexigrid Opsite (type of dressing) had expired on 5/21, - 6 packs of IV start kits had expired on 8/10/22, - 23 packs of IV start kits had expired on 1/15/23, and - one pack of IV start kit had expired on 1/5/23. RN 1 verified the above expired IV supplies in Medication Cart 3. When asked if the above supplies should be in the medication cart, RN 1 stated the supplies should be discarded when expired. On 2/9/23 at 1309 hours, an interview was conducted with the DON. When asked if the expired supplies should be in the medication cart, the DON stated the expired supplies in the medication cart should be disposed and reordered.3. Review of the facility's P&P titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles dated April 2022 showed the facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by the residents and visitors. On 2/7/23 at 1222 hours, two packets of A&D ointment (a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) were observed on the base of the hand sanitizer dispenser located in the hallway next to Resident 736's room. One of the two packets was opened and the other was sealed. On 2/7/23 at 1236 hours, a concurrent observation and interview was conducted with CNA 1. CNA 1 verified the above findings. CNA 1 stated it was not the right place to store the A&D ointment, and the A&D packets should not have been placed on the hand sanitizer dispenser. CNA 1 stated the A&D ointment was supposed to be kept with the treatment nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 23 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm On 2/8/23 at 0853 hours, an interview was conducted with RN 1. RN 1 stated the A&D ointment was to be stored in the treatment cart. RN 1 stated the staff were not allowed to leave medications in the hallways. On 2/10/23 at 0924 hours, an interview was conducted with the DON. When asked where the treatment ointments and supplies should be kept, the DON stated they should be kept in the treatment cart. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 24 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. Residents Affected - Some * The facility failed to ensure the expired food items in the walk-in refrigerator and dry storage area were discarded. * The facility failed to ensure the labeling and dating of foods in the kitchen and refrigerator used for the residents' food brought in by the visitors were proper. * The facility failed to ensure the kitchen equipment was clean. * The facility failed to ensure the resident dishware and utensils had a smooth cleanable surface. * The facility failed to ensure the sanitizer test strips had not expired. * The facility failed to ensure the backflow prevention of one air gap was properly maintained. These failures had the potential to cause the foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 2/7/23, showed 32 of 32 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Storage revised 11/1/14, showed the food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded. a. On 2/7/23 at 0839 hours, during the initial tour of the main kitchen, an opened bottle of Hershey's chocolate sauce with a use-by-date of 2/6/23, was observed inside the refrigerator. [NAME] 1 verified the finding. b. On 2/7/23 at 0854 hours, a bin containing breadcrumbs with a use-by-date of 1/10/23, was observed inside the dry storage area of the main kitchen. [NAME] 2 verified the finding. c. On 2/7/23 at 0900 hours, an opened bottle of Tajin with a use-by-date of 2/6/23 was observed on the kitchen counter in the main kitchen, and a bin containing white onions with a use-by-date of 2/6/23, was observed below the kitchen preparation table counter in the main kitchen. The Production Chef verified the findings. 2.a. Review of the facility's P&P titled Food Storage revised 11/1/14, showed all products should be dated upon receipt and when they are prepared; and use use by dates on all food stored in refrigerators. On 2/7/23 at 0839 hours, during the initial tour of the main kitchen. The following was observed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 25 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 - five opened bags of bread with no opened dates and use-by dates were stored in the bread storage rack; Level of Harm - Minimal harm or potential for actual harm - an opened bottle of Butter-it Creamy Soybean Liquid butter alternative with no opened date and use-by-date Residents Affected - Some - an opened bottle of vegetable oil with no opened date and use-by-date; - an opened can of griddle and cooking spray with no opened date and use-by-date; - two opened bottle with yellow liquid sauce with no label, opened date and use-by-date; and - an opened bottle with pale yellow liquid with no label, opened date and use-by-date; Cook 2 verified the above findings. b. On 2/7/23 at 0900 hours, the following was observed in the main kitchen: - a half of a cut onion wrapped in a cling wrap with no preparation date and use-by-date in a bin of onions; and - a half of a cut potato wrapped in a cling wrap with no preparation date and use-by-date in a bin of potatoes. The Production Chef verified the above findings. The Production Chef stated the sliced onion and potato should have been labeled with the preparation date and use-by-date and should have been stored inside the refrigerator. c. Review of the facility's document titled Resident's Refrigerator (undated) showed to ensure the food items are properly stored/covered and labeled with the following information: the resident's name, resident's room number, and date stored. Items will be discarded 72 hours after date stored. On 2/8/23 at 0820 hours, an observation of the residents' refrigerator located in the staff lounge was conducted with the DSS. An opened bottle of soda with no label was observed inside the residents' refrigerator. The DSS verified the findings. 3. According to the USDA Food Code 2017, 4-602.13, Non-Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. a. On 2/8/23 at 0819 hours, a storage rack storing bowls was observed with dried black particles. The DSS verified the findings and stated the storage rack should have been properly cleaned before storing the bowls. b. On 2/8/23 at 1555 hours, the heated plate lowerator (a spring-activated device which heats and raises stacks of plates to service level position) was observed with dried black particles. The DSS verified the findings and stated she would ask the maintenance to clean the plate lowerator. 4. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 26 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. a. On 2/8/23 at 0819 hours, a spatula with chipped handle was observed inside a bin with scoops. The DSS verified the findings. b. On 2/8/23 at 1600 hours, the plate domes and bottom plates were observed on the shelf near the tray line area. Several plate domes and bottom plates were observed with chipped edges. The Director of Dietary Services verified the findings. 5. According to the USDA Food Code 2017, 4-701.10, Food Contact Surfaces and Utensils, effective sanitization procedures destroy organisms of public health importance that may be present on wiping cloths, food equipment, or utensils after cleaning, or which have been introduced into the rinse solution. Review of the manufacturer's safety information on the sanitizer test strips (undated), underTesting Use Solution Concentration, showed the shelf-life for the sanitizer test strips is two years. On 2/9/23 at 1330 hours, an observation of the sanitization solution test was conducted with the Dietary Aide. The Dietary Aide checked the concentration of the sanitizer using a paper test strip taken from a bottle of sanitizer test strips. The sanitizer test strip container had an expiration date of 09/2022. On 12/9/22 at 0858 hours, an interview was conducted with the Dietary Services Director. The Director of Dietary Services verified the sanitizer test paper had expired. 6. According to the USDA Food Code 2017, 5-202.13, Backflow prevention, Air Gap, an air gap between the water supply inlet and flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm. On 2/8/23 at 1110 hours, an observation in the main kitchen area was conducted. Two metal pipes and three hoses were observed below the flood level and into the drainage inlet. [NAME] 2 verified the findings and stated the maintenance department was responsible for the drainpipes in the kitchen. On 2/9/23 at 1402 hours, an observation in the main kitchen area and concurrent interview was conducted with the Director of Maintenance and Maintenance Supervisor. The two drainpipes were observed above the flood level of the drainage inlet; however, the three hoses were observed below the flood level and into the drainage inlet. The Director of Maintenance and Maintenance Supervisor verified the findings. The Director of Maintenance stated the two drainpipes and two hoses were connected to the steamer, and one hose was connected to the water filtration system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 27 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the rehabilitation services for one of 14 final sampled residents (Resident 30). Residents Affected - Few * The facility failed to ensure Resident 30 was provided RNA services for ambulation when Resident 30 was in isolation for Covid-19. This failure had the potential for Resident 30 to decline in the resident's range of motion and mobility. Findings: On 2/7/23 at 1124 hours, during the initial tour of the facility, an interview was conducted with Resident 30. Resident 30 stated she was supposed to walk, but it was stopped while she was in isolation for Covid-19. Resident 30 stated she was out of the isolation for Covid-19 on Thursday, and the staff started to walk her again. Resident 30 stated she felt she was relearning to walk again. Medical record review for Resident 30 was initiated on 2/7/23. Resident 30 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 30 was cognitively intact and required extensive assistance of one person for walking. Review of Resident 30's Order Summary Report showed the following physician's orders dated: - On 1/4/23, RNA ambulation with FWW (front-wheeled walker) five times per week daily as tolerated; and - On 1/23/23, to hold RNA ambulation for duration of Covid isolation, and the resident to ambulate with RCA (resident care ambassador, CNA) as tolerated. Review of Resident 30's RNA Monthly Report for January and February 2023 showed Resident 30 was documented as hold from 1/23 to 2/2/23. Review of Resident 30's Documentation Survey Report v2 for January and February 2023, under the section for walk in room showed Resident 30 was documented as 97 which meant not applicable from 1/22 to 2/3/23. Review of the Resident 30's Progress Notes showed a health status note dated 1/23/23, showing Resident 30 was tested positive for Covid-19 and was transferred to another room. Further review of the progress notes showed Resident 30 was afebrile and had no cough, no congestion, nor shortness of breath. Review of Resident 30's Medication Administration Record showed Resident 30 was administered Safe Tussin DM (cough medication) on 1/27/23 at 1330 hours. On 2/9/23 at 1050 hours, an interview and concurrent medical record review was conducted with RNA 2. When asked about RNA services provided for Resident 30, RNA 2 stated Resident 30 had an order for ambulation with RNA; however, the RNA services were put on hold because she was in isolation for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 28 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 Covid-19. RNA 2 stated they documented this in the RNA Monthly Report form. Level of Harm - Minimal harm or potential for actual harm On 2/9/23 at 1453 hours, an interview and concurrent medical record review was conducted with the MDS/Case Management Director. The MDS/Case Management Director verified the above findings. The MDS/Case Management Director stated he was in charge of the RNA program. When asked about RNA services provided for Resident 30, the MDS/Case Management Director stated the RNA services for ambulation was not provided to Resident 30 because of the resident's COVID-19 positive status, and isolation from 1/23 to 2/3/23. When asked why RNA services were on hold when Resident 30 was in isolation for Covid-19, the MDS/Case Management Director stated Resident 30 was coughing and could not tolerate the RNA services. However, the MDS/Case Management Director could not find documentation showing Resident 30 could not tolerate RNA services while in isolation for Covid-19. The MDS/Case Management Director showed the MAR showing Resident 30 was given a one dose of cough medication on 1/27/23. When asked for documentation when he spoke with the physician regarding holding the RNA services for the residents on isolation for Covid-19, the MDS/Case Management Director could not find any documentation. Residents Affected - Few On 2/10/23 at 0831 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. When asked why RNA services were on hold when Resident 30 was in isolation for Covid-19, the DON stated the RNA services should not have stopped even if the resident was in isolation for Covid-19 unless the resident could not tolerate the ambulation. The DON stated the RNA services for ambulation was supposed to be done by the CNA while Resident 30 was in isolation for Covid-19. The DON could not find documentation the CNA ambulated Resident 30 while in isolation for Covid-19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 29 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Isolating Residents During COVID-19 (undated) showed it is the facility's policy to maintain procedures for isolating COVID-19 positive residents. Further review of the facility's P&P showed the resident in a COVID-19 positive room will be assessed by a licensed nurse every four hours documenting Resident respiratory rates, temperatures, and oxygen saturation levels. Residents Affected - Some Review of Resident 25's medical record was initiated on [DATE]. Resident 25 was admitted to the facility on [DATE]. Review of the facility's document titled COVID-19 SNF Resident Surveillance Test as of [DATE] showed Resident 25 was tested positive for COVID-19. Review of the Order Summary Report for [DATE] failed to show an order to monitor Resident 25'srespiratory rates, temperatures, and oxygen saturation levels every four hours. Review of Resident 25's eMAR for [DATE], failed to show Resident 25's monitoring forrespiratory rates, temperatures, and oxygen saturation levels every four hours as per the facility's P&P. On [DATE] at 0914 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 was informed and verified the above findings. LVN 3 stated it should have been monitored every four hours as per the facility's policy and to evaluate the resident's condition. On [DATE] at 0932 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON further stated it should be monitored to provide proper care for the resident. 4. On [DATE] at 1206 hours, a medication administration observation for Resident 16 was conducted with LVN 2. LVN 2 was observed to find Resident 16's Novolin R FlexPen in Medication Cart 2 had expired. LVN 2 obtained a new vial of Novolin R insulin medication from the facility's emergency kit. LVN 2 was observed removing the plastic top of the insulin vial, withdrawing the medication from the vial, and administering the insulin to Resident 16 via subcutaneous injection. LVN 2 did not disinfect the self-sealing stopper top of the insulin vial with an antimicrobial swab prior to withdrawing the insulin. On [DATE] at 1229 hours, an interview was conducted with LVN 2. When asked if LVN 2 disinfected the top of the insulin vial, LVN 2 acknowledge the above findings. On [DATE] at 1309 hours, an interview was conducted with the DON. When asked if the nurse was supposed to disinfect the top of the vial after opening, the DON stated the nurse was supposed to wipe the top of the vial with alcohol. Cross reference to F761, example #1. Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to maintain the infection control program designed to provide the safe environment and reduce the risk of development of illnesses and transmission of diseases. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 30 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some * The facility failed to show documentation of the Legionella (a bacteria that can cause a serious type of lung infection) facility risk assessment and testing protocols. * The facility failed to implement proper hand hygiene and changing gloves during wound care. * The facility failed to ensure a confirmed COVID-19 case was assessed every four hours for respiratory rates, temperatures, and oxygen saturation levels as per the facility's P&P for Resident 25. * LVN 2 failed to disinfect the self-sealing stopper top of the insulin (medication to lower blood sugar) vial prior to withdrawing the medication. This posed a risk for increased infection. These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility. Findings: 1. According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated [DATE], the facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation to ensure each facility: - Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. - Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained. Review of the facility's P&P titled Water Management revised [DATE] showed the facility supports the prevention, detection, and control of water-borne containments, including Legionella. Further review of the policy showed it did not include methods to identify or test for waterborne pathogens. Review of the Facility Assessment revised [DATE], showed no risk assessments or methods listed to identify and test for Legionella and waterborne pathogens in the water management program. On [DATE] at 1110 hours, an interview was conducted with the DSD/IP. The DSD/IP acknowledged there was no water management program policy for Legionella in the Infection Control binder. On [DATE] at 1124 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the water was routinely checked for leaking and spills; however, it was not tested. On [DATE] at 1237 hours, an interview was conducted with the Administrator and DON. The Administrator and DON verified there was a P&P for Water Management; however, the policy did not include the risk assessment or testing methods to identify and test for Legionella. The Administrator and DON acknowledged the facility should have had a documented risk assessment and testing methods in the water management plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 31 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of the facility's P&P titled Handwashing/Hand Hygiene revised [DATE], showed all personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Review of the facility's P&P titled Infection Prevention and Control Guidelines revised [DATE], showed employees must wash their hands, scrubbing for twenty seconds using soap and water under the following conditions: before and after direct contact with residents; after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; and after removing gloves. Review of the facility's P&P titled Wound Care/Change of dressing revised [DATE], showed the following: - Wash hands (alcohol-based hand rub may be used at this point). Apply clean gloves. - Remove of dressing and discard in the appropriate disposal bag. - Remove gloves. Wash hands (alcohol-based hand rub may be used at this point). Apply clean gloves. - Cleanse wound with solution ordered. Do not directly touch any item that will come in contact with the wound. Wash from the center of the wound to the periphery. Always wash from the area of least contamination to the area of most contamination. - Observe the wound for size, color, drainage, appearance, and amount of drainage. Measure the area before any medication is applied. - Remove gloves. Wash hands (alcohol-based hand rub may be used at this point). Apply clean gloves. - Apply ointment, cream, or any medication ordered and dress the wound. - Discard soiled materials in plastic bag. - Remove gloves and wash hands. Medical Record review for Resident 17 was initiated on [DATE]. Resident 17 was admitted on [DATE]. Review of Resident 17's plan of care showed a care plan problem dated [DATE], addressing pressure injury to the: coccyx, with the interventions including to observe good infection control when dealing with ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin). On [DATE] at 1408 hours, a wound care observation and concurrent interview was conducted with RN 1. RN 1 donned new gloves, entered Resident 17's room to greet Resident 17 and CNA 1, then went back to the treatment cart to gather supplies. RN 1 discarded his used gloves. RN 1 then donned new gloves and started with Resident 17's wound treatment. RN 1 positioned Resident 17 on her left side. RN 1 proceeded to remove Resident 17's sacrococcyx wound dressing, discarded the wound dressing in a trash bin next to the bed, then cleansed the wound with a new normal saline soaked gauze. RN 1 then removed his gloves and went to the treatment cart to gather more supplies. RN 1 put on new gloves; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 32 of 33 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some however, RN 1 did not perform hand hygiene. RN 1 then dressed the wound with a new dressing. Afterwards, RN 1 prepared a new dressing for Resident 17's right nephrostomy tube (a thin plastic tube passed from the back, thrugh the skin and then through the kidney, to the point where the urine collects to temporarily drain the urine that is blocked) without changing his gloves or performing hand hygiene. RN 1 then removed the old nephrostomy tube dressing and placed the new dressing at the site. Resident 17 was then repositioned on her back by CNA 1 and RN 1. RN 1did not perform hand hygiene or change his gloves. RN 1 proceeded to change the dressing on Resident 17's abdominal wound. RN 1 removed and discarded the old dressing, cleansed the wound with a normal saline soaked gauze, and placed a new dressing on Resident 17s' abdominal wound. RN 1 then removed his used gloves and went back to the treatment cart for more supplies. RN 1 did not perform hand hygiene but put on new gloves. Resident 17 was then turned to her right side by CNA 1. RN 1 removed and discarded Resident 17's old left nephrostomy tube dressing, then placed a new dressing to the tube site. RN 1 did not perform hand hygiene or change gloves prior to, during, or after the wound care was performed. When asked what the expectation was regarding hand washing during wound care, RN 1 stated he was expected to change his gloves and wash his hands in between wound care. When asked why he did not change his gloves or wash his hands when working with Resident 17's different wound sites, RN 1 stated he forgot. On [DATE] at 0924 hours, an interview was conducted with the DON. The DON stated the staff should be washing their hands before putting on gloves. The DON further stated the staff should be performing hand hygiene and changing gloves in between different wound sites. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555391 If continuation sheet Page 33 of 33

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Citations

14 citations recorded^*CMS

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.

0679GeneralS&S Dpotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0685GeneralS&S Dpotential for harm
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
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.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
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.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0553GeneralS&S Dpotential for harm
F553 - The right to participate in the development and implementation of his or her
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
0554GeneralS&S Dpotential for harm
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
0623GeneralS&S Dpotential for harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0825GeneralS&S Dpotential for harm
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the February 10, 2023 survey of FREEDOM VILLAGE HEALTHCARE CENTER?

This was a inspection survey of FREEDOM VILLAGE HEALTHCARE CENTER on February 10, 2023. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at FREEDOM VILLAGE HEALTHCARE CENTER on February 10, 2023?

Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide activities to meet all resident's needs."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·February 10, 2023