Freedom Village Healthcare Center

Freedom Village Healthcare Center was recognized and ceritified in 1989 by Centers for Medicare & Medicaid Services as one of model nursing home providers promoting health and improving quality of life. Freedom Village Healthcare Center which is located in 23442 El Toro Road Lake Forest, is scientifically measured and assessed by Centers for Medicare & Medicaid Services and is shown to provide good nursing home services or products under the Medicare program. Freedom Village Healthcare Center is being offered ceritified services and products in California.
Address:   23442 El Toro Road
       Lake Forest, CA 92630

Phone:   (949) 472-0277

County: Orange
Federal Provider Number: 555391
Participates in: Medicare And Medicaid
Certified Date: Thursday, October 26, 1989 (35 years certified)
Certified Agency: Centers for Medicare & Medicaid Services
Legal Business Name: Casa Pacifica
Ownership Type: For Profit - Partnership
Provider Changed Ownership in Last 12 Months: No



TypeNameRole Description
OrganizationThe Mangiaracina-Roskamp Family Trust Dated 11/17/1998General Partnership Interest
OrganizationThe Francese Family Trust Dated 6/25/1996General Partnership Interest
OrganizationTarayan IncGeneral Partnership Interest
OrganizationTarayan Inc5% Or More Ownership Interest
OrganizationStringer Family PartnershipGeneral Partnership Interest
OrganizationStringer Enterprises LlcGeneral Partnership Interest
OrganizationStringer Enterprises Llc5% Or More Ownership Interest
OrganizationRoskamp Family Trust Dated 1/21/85General Partnership Interest
OrganizationRoskamp Family Trust Dated 1/21/855% Or More Ownership Interest
OrganizationNelson Edward Murphy TrustGeneral Partnership Interest
OrganizationNelson Edward Murphy Trust5% Or More Ownership Interest
OrganizationHemet Retirement PropertiesGeneral Partnership Interest
OrganizationHemet Retirement Properties5% Or More Ownership Interest
OrganizationFreedom Properties West LlcGeneral Partnership Interest
OrganizationFreedom Properties West Llc5% Or More Ownership Interest
OrganizationFreedom Group-California LlcGeneral Partnership Interest
OrganizationFreedom Group-California Llc5% Or More Ownership Interest
OrganizationCasa PacificaOperational/managerial Control
OrganizationCasa Pacifica5% Or More Ownership Interest
OrganizationThe Wade Family Trust Dated 04/05/20015% Or More Ownership Interest
OrganizationThe Wade Family Trust Dated 04/05/2001General Partnership Interest
PersonThomas StringerOperational/managerial Control
PersonCheryl RoskampOperational/managerial Control
PersonJoel NiblettW-2 Managing Employee
PersonBarbara JohnstonW-2 Managing Employee
PersonBarbara JohnstonDirector/officer
PersonMarianne CasinoOperational/managerial Control

Provider Resides in Hospital: No
Number of Federally Certified Beds: 52
Number of Residents in Federally Certified Beds: 37 (72% occupied)
Continuing Care Retirement Community: Yes
Special Focus Facility: No
With a Resident and Family Council: Resident
Automatic Sprinkler Systems in All Required Areas: Yes


Survey Date: Tuesday, January 14, 2014
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 3, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, January 14, 2014
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 3, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, January 14, 2014
Survey Type: Fire Safety
Deficiency: K0027 (Smoke barrier doors that can resist smoke for at least 20 minutes.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 3, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, January 14, 2014
Survey Type: Fire Safety
Deficiency: K0012 (Approved construction type or materials.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 3, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, January 14, 2014
Survey Type: Fire Safety
Deficiency: K0051 (A fire alarm system that can be heard throughout the facility.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 3, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, January 14, 2014
Survey Type: Fire Safety
Deficiency: K0054 (Properly maintained smoke detectors.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 3, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, January 14, 2014
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 3, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, January 14, 2014
Survey Type: Fire Safety
Deficiency: K0064 (Portable fire extinguishers.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 3, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, January 14, 2014
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 3, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0465 (Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staf)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0356 (Post nurse staffing information/data on a daily basis.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0518 (Train all employees on what to do in an emergency, and carry out unannounced staff drills.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0325 (Ensure residents maintain acceptable nutritional status.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0156 (Give residents a notice of rights, rules, services and charges.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0334 (Develop policies and procedures for influenza and pneumococcal immunizations.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0428 (At least once a month, have a licensed pharmacist review each resident's medication (s) and report a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: B
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 9, 2014
Survey Type: Health
Deficiency: F0167 (Allow residents to easily view the results of the nursing home's most recent inspection.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, February 7, 2013
Survey Type: Fire Safety
Deficiency: K0033 (Protected exits that allow the resident to escape the building.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, February 7, 2013
Survey Type: Fire Safety
Deficiency: K0021 (Exit doors that are held open by devices that will automatically close on the activation of a fire a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, February 7, 2013
Survey Type: Fire Safety
Deficiency: K0067 (Heating and ventilation systems that have been properly installed according to the manufacturer's in)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, February 7, 2013
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, February 7, 2013
Survey Type: Fire Safety
Deficiency: K0054 (Properly maintained smoke detectors.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, February 7, 2013
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, February 7, 2013
Survey Type: Fire Safety
Deficiency: K0027 (Smoke barrier doors that can resist smoke for at least 20 minutes.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, February 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 31, 2013
Survey Type: Health
Deficiency: F0428 (At least once a month, have a licensed pharmacist review each resident's medication (s) and report a)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, March 2, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 31, 2013
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, March 2, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 31, 2013
Survey Type: Health
Deficiency: F0328 (Properly care for residents needing special services, including: injections, colostomy, ureostomy, i)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, March 2, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 31, 2013
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, March 2, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 31, 2013
Survey Type: Health
Deficiency: F0273 (Assess in a timely manner the resident when the resident enters the nursing home.)
Scope Severity Code: B
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, March 2, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 31, 2013
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, March 2, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, March 6, 2012
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, April 18, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, March 6, 2012
Survey Type: Fire Safety
Deficiency: K0064 (Portable fire extinguishers.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, April 18, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, March 6, 2012
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, April 18, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, March 6, 2012
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, April 18, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, March 6, 2012
Survey Type: Fire Safety
Deficiency: K0012 (Approved construction type or materials.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, April 18, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0176 (Allow residents to self-administer drugs if determined safe.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0518 (Train all employees on what to do in an emergency, and carry out unannounced staff drills.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0154 (Ensure that residents are fully informed and understand their health status, care and treatments.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0386 (Make sure that doctors see a resident's plan of care at every visit and make notes about progress an)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0520 (Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, a)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0361 (Hire a qualified dietician.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0311 (Make sure that residents receive treatments/services to maintain or improve their ability to care fo)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0465 (Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staf)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0278 (Ensure each resident receives an accurate assessment by a qualified health professional.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0356 (Post nurse staffing information/data on a daily basis.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 2, 2012
Survey Type: Health
Deficiency: F0328 (Properly care for residents needing special services, including: injections, colostomy, ureostomy, i)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, April 2, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0154 (Ensure that residents are fully informed and understand their health status, care and treatments.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0273 (Assess in a timely manner the resident when the resident enters the nursing home.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0328 (Properly care for residents needing special services, including: injections, colostomy, ureostomy, i)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0164 (Keep residents' personal and medical records private and confidential.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0250 (Provide medically-related social services to help each resident achieve the highest possible quality)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0311 (Make sure that residents receive treatments/services to maintain or improve their ability to care fo)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0502 (Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Monday, October 3, 2011
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: B
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Wednesday, November 2, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Number of Facility Reported Incidents: 0
Number of Substantiated Complaints: 2
Number of Fines: 0
Number of Payment Denials: 0
Total Number of Penalties: 0
Total Amount of Fines in Dollars: USD 0
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This data was updated by using data source from Centers for Medicare and Medicaid Services (CMS) which is publicized on Wednesday, October 1, 2014. If you found out that something incorrect and want to change it, please follow this Update Data guide.

The Five Star Quality Rating System is not a substitute for visiting the nursing home. This system can give you important information, help you compare nursing homes by topics you consider most important, and help you think of questions to ask when you visit the nursing home. Use the Five-Star ratings together with other sources of information.

items rating
Health Inspection Rating (2 out of 5 stars)
Quality Rating (5 out of 5 stars)
Staffing Rating (5 out of 5 stars)
RN Staffing Rating (5 out of 5 stars)
Overall Rating (4 out of 5 stars)
Nursing homes vary in the quality of care and services they provide to their residents. Reviewing health inspection results, staffing data, and quality measure data are three important ways to measure nursing home quality. This information gives you a "snap shot" of the care individual nursing home give.


Patients experiences Provider State Nation
Percent of High Risk Long Stay Residents With Pressure Ulcers
N/A
6%
6%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury
N/A
2%
3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain
N/A
5%
8%
Percent of Long Stay Residents Who Were Physically Restrained
N/A
2%
1%
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased
N/A
12%
16%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder
N/A
3%
3%
Percent of Long Stay Residents With a Urinary Tract Infection
N/A
5%
6%
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain
N/A
16%
19%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened
N/A
1%
1%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
94%
94%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
93%
94%
Percent of Long Stay Residents Who Have Depressive Symptoms
N/A
2%
6%
Percent of Long Stay Residents Who Lose Too Much Weight
N/A
6%
7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication
N/A
16%
20%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder
N/A
45%
44%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine
N/A
81%
83%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication
N/A
2%
2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
N/A
82%
84%

N/A
Data not available.

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Freedom Village Healthcare Center [Federal No:555391] near 23442 El Toro Road, Lake Forest CA

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