Inspection Reports for
Freedom Village Retirement Community
23442 El Toro Rd Building 1, Lake Forest, CA 92630, CA, 92630
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
19.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
383% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Nov 26, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the facility's adherence to standards related to resident care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including medication self-administration safety, call light accessibility, resident rights education, abuse reporting and investigation, transfer/discharge notification, respiratory care, medication administration accuracy, medication storage and labeling, food safety and sanitation, medical record accuracy, infection control program implementation, antibiotic stewardship, and immunization education and documentation.
Deficiencies (16)
Failed to determine if residents were safe to self-administer medications; medications were left at bedside without physician orders or care plans.
Failed to ensure call light was visible and within reach for a resident, posing risk of delayed assistance.
Failed to provide residents with information on how to contact the local State agency for complaints.
Failed to timely report an allegation of abuse to appropriate authorities.
Failed to ensure transfer/discharge notification was sent to the LTC Ombudsman.
Failed to provide necessary care and physician notification following an abuse allegation.
Failed to maintain safe water temperature levels, with multiple rooms exceeding 120 degrees Fahrenheit.
Failed to provide respiratory care as ordered, including incorrect oxygen flow rates and unlabeled oxygen tubing.
Medication administration errors observed, including failure to administer medications with meals as ordered.
Failed to ensure proper medication storage, labeling, and cleanliness, including presence of unauthorized creams and unclean medication refrigerator.
Failed to maintain sanitary conditions in the kitchen, including unlabeled food items, dirty ice machine, and improper drying of utensils.
Failed to maintain accurate medical records documenting nebulizer treatments for residents.
Failed to implement infection prevention and control program adequately, including incomplete infection surveillance documentation and failure to place resident on enhanced barrier precautions (EBP).
Failed to monitor antibiotic use appropriately, including use of antibiotics without meeting infection criteria and lack of physician follow-up.
Failed to provide education and documentation regarding influenza, pneumococcal, and COVID-19 vaccinations to residents and/or their representatives.
Failed to offer COVID-19 seasonal vaccine to eligible residents.
Report Facts
Medication error rate: 8
Rooms with water temperature above 120°F: 12
Total infections: 17
Community Acquired Infection (CAI): 10
Healthcare Associated Infection (HAI): 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Named in medication error findings for failure to administer medications as ordered |
| LVN 4 | Licensed Vocational Nurse | Verified medication self-administration issues for Residents 66 and 68 |
| CNA 3 | Certified Nursing Assistant | Acknowledged call light visibility issue for Resident 27 |
| DON | Director of Nursing | Verified multiple findings including medication self-administration, abuse reporting, respiratory care, infection control, and vaccination education |
| Administrator | Interviewed regarding abuse reporting and other findings | |
| Maintenance Director | Verified water temperature findings | |
| DSD/IP | Director of Staff Development/Infection Preventionist | Verified infection control and antibiotic stewardship findings |
| CDM/Executive Chef | Verified food safety and sanitation findings | |
| LVN 1 | Licensed Vocational Nurse | Verified medication storage and labeling deficiencies |
| RN 1 | Registered Nurse | Verified oxygen tubing labeling deficiency |
| LVN 5 | Licensed Vocational Nurse | Observed failing to perform hand hygiene and oxygen administration errors |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure a resident received appropriate nutritional services and timely physician notification of dietitian recommendations.
Complaint Details
The complaint investigation found that the facility failed to ensure one of four sampled residents received appropriate nutritional services and timely physician notification of dietitian recommendations. The delay was substantiated and acknowledged by the Director of Nursing.
Findings
The facility failed to timely notify Resident 3's physician of the registered dietitian's recommendations following a significant weight loss, potentially risking further weight loss, dehydration, and poor wound healing. The delay in implementing nutritional interventions was acknowledged by the Director of Nursing.
Deficiencies (1)
Failure to timely notify Resident 3's physician of the registered dietitian's recommendations after a 6-pound weight loss in six days.
Report Facts
Weight loss: 6
Days delay: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Verified nutrition assessment and timing of RD recommendations |
| DON | Director of Nursing | Acknowledged findings and responsibility for delay in relaying RD recommendations |
Inspection Report
Deficiencies: 1
Date: Dec 26, 2024
Visit Reason
The inspection was conducted to evaluate the accuracy of medical records and compliance with facility policies regarding fall risk assessment and documentation.
Findings
The facility failed to ensure the medical record was accurate for one sampled resident, specifically the fall risk assessment was inaccurately documented, posing a risk for the resident to not receive accurate and necessary care.
Deficiencies (1)
Failure to ensure the medical record was accurate for Resident 1, specifically the fall risk assessment was inaccurately documented as no falls instead of one to two falls.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Verified the fall risk assessment was inaccurate and stated the licensed nurse did the fall risk assessment. | |
| ADON | Acknowledged the licensed nurse documented no history of falls and stated the licensed nurse should have updated the fall risk assessment. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 6, 2024
Visit Reason
The inspection was conducted following a complaint alleging physical abuse by two CNAs against Resident 1 on 11/10/24. The investigation focused on the facility's response to the abuse allegation and the adequacy of care and monitoring provided to Resident 1.
Complaint Details
The complaint investigation was substantiated by findings that the facility did not suspend the alleged CNAs during the investigation and failed to monitor and develop a care plan for Resident 1 following the abuse allegation.
Findings
The facility failed to suspend the two CNAs during the investigation period, potentially placing Resident 1 and others at risk. Additionally, the facility did not monitor Resident 1 for 72 hours post-allegation nor develop a care plan addressing safety and psychosocial wellbeing after the abuse report.
Deficiencies (2)
Failure to suspend CNAs 2 and 3 from work during the investigation period after an abuse allegation.
Failure to monitor Resident 1's safety and psychosocial wellbeing for 72 hours and to develop a care plan after the abuse allegation.
Report Facts
Dates CNAs worked post-allegation: 3
Investigation period: 4
Monitoring period: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Named in abuse allegation and investigation findings. |
| CNA 3 | Certified Nursing Assistant | Named in abuse allegation and investigation findings. |
| RN 1 | Registered Nurse | Verified findings regarding lack of care plan and monitoring for Resident 1. |
| DON | Director of Nursing | Acknowledged findings and confirmed that CNAs should have been suspended and care plan/monitoring should have been implemented. |
Inspection Report
Annual Inspection
Deficiencies: 20
Date: Oct 24, 2024
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including medication self-administration, advance directive documentation, Medicare non-coverage notices, nutritional interventions for weight loss, respiratory care, pharmaceutical services, medication regimen monitoring, medication storage and labeling, food service management, hospice services, quality assurance processes, infection prevention and control, antibiotic stewardship, immunization policies, and equipment maintenance.
Deficiencies (20)
Failure to ensure safe self-administration of medications for Resident 24 without physician's order or care plan.
Failure to document and provide advance directive information for Residents 22, 24, and 25.
Failure to provide Notice of Medicare Non-Coverage to residents 45 and 47 after Medicare Part A termination.
Failure to ensure timely nutritional intervention for Resident 22 after significant weight loss.
Failure to provide appropriate respiratory care including sanitary storage and dating of oxygen equipment for Residents 17 and 22.
Failure to ensure accurate reconciliation and disposal of controlled medications in the Omnicell system.
Failure to properly monitor stool softener medication administration for Resident 12.
Failure to ensure Resident 25 was free from unnecessary psychotropic medications and lacked documentation of behavioral monitoring and non-pharmacological interventions.
Failure to ensure proper storage, labeling, and cleanliness of medications and medication carts; leaving medications unattended.
Failure to employ a qualified Dietetic Services Supervisor to oversee the satellite kitchen.
Failure to follow main menu for 42 residents and failure to notify residents of menu changes.
Failure to prevent serving food allergy item (cucumber) to Resident 27 with known allergy.
Failure to maintain food safety and sanitation in kitchen including unclean utensils, improper cleaning, and lack of air gap on juice machine.
Failure to provide education on safe food handling practices to staff and family/visitors regarding outside food.
Failure to provide ordered hospice aide visits and include hospice RN in care planning for Resident 22.
Failure to identify and develop corrective action plans for respiratory care and medication storage deficiencies in QA committee.
Failure to perform hand hygiene appropriately and maintain Foley catheter care in a sanitary manner for Resident 686; failure to maintain accurate infection surveillance and infection control practices.
Failure to implement antibiotic stewardship program including inappropriate antibiotic use and lack of physician notification.
Failure to ensure Residents 4 and 25 were offered influenza and pneumococcal vaccines with proper documentation of informed consent and refusal.
Failure to maintain essential temperature logs for the Omnicell Automated Drug Delivery System, risking medication efficacy.
Report Facts
Weight loss percentage: 5.32
Number of residents affected by menu issue: 42
Number of residents affected by food allergy issue: 1
Number of residents affected by hospice service failure: 1
Number of residents affected by antibiotic stewardship failure: 3
Number of residents affected by vaccine offering failure: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Verified medication self-administration and respiratory care findings |
| LVN 1 | Licensed Vocational Nurse | Observed leaving medications unattended and failed hand hygiene during medication administration |
| LVN 2 | Licensed Vocational Nurse | Observed medication cart issues and stool softener administration |
| LVN 3 | Licensed Vocational Nurse | Acknowledged oxygen tubing storage issues and medication chart checking practices |
| DON | Director of Nursing | Acknowledged multiple findings including medication storage, hospice care, QA processes, and temperature log issues |
| DSS | Dietary Service Supervisor | Acknowledged menu changes, food allergy incident, and education failures |
| DSD/IP | Director of Staff Development/Infection Preventionist | Verified infection control and antibiotic stewardship deficiencies |
| Pharmacy Staff 1 | Pharmacy Staff | Reported non-compliance with controlled medication counts |
| Maintenance Technician | Maintenance Technician | Verified juice machine lacked air gap |
| Administrator | Facility Administrator | Acknowledged multiple findings including food service and infection control issues |
| CNA 1 | Certified Nursing Assistant | Observed improper Foley catheter care |
Inspection Report
Routine
Deficiencies: 4
Date: Oct 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, respiratory care, nutrition, and antibiotic stewardship at Freedom Village Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to implement two-person assist for transfers resulting in a resident's ankle fracture, improper storage and dating of respiratory equipment, failure to follow the main menu for meals served to residents, and inadequate implementation of the antibiotic stewardship program with inappropriate antibiotic use for several residents.
Deficiencies (4)
Failure to ensure staff implemented two-person assist for transfers for Resident 18, resulting in a right ankle fracture.
Failure to ensure proper sanitary storage and dating of nasal cannula tubing and respiratory storage bags for Residents 17 and 22.
Failure to follow the main menu for 42 residents consuming food prepared in the kitchen, with no evidence residents were notified of menu changes.
Failure to implement an antibiotic stewardship program ensuring appropriate antibiotic use for Residents 9, 20, and 25, with lack of documentation and physician notification regarding criteria for antibiotic use.
Report Facts
Residents affected: 42
Antibiotic treatment duration: 5
Antibiotic treatment duration: 5
Antibiotic treatment duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Interviewed regarding transfer of Resident 18 without two-person assist |
| Case Manager | Verified care plan and need for two-person assist for Resident 18 | |
| Director of Rehabilitation | Verified Resident 18's need for two-person assist due to knee osteoarthritis and weakness | |
| LVN 3 | Licensed Vocational Nurse | Verified findings regarding Resident 17's nasal cannula storage |
| LVN 2 | Licensed Vocational Nurse | Verified findings regarding Resident 22's nasal cannula and respiratory storage bag |
| DSS | Director of Food and Nutrition Services | Acknowledged main menu was not followed and residents were not notified |
| DSD/IP | Director of Staff Development/Infection Preventionist | Verified antibiotic stewardship program deficiencies |
| RN 1/IP | Registered Nurse/Infection Preventionist | Verified antibiotic stewardship program deficiencies |
| Administrator | Acknowledged antibiotic stewardship findings | |
| DON | Director of Nursing | Acknowledged findings regarding respiratory care and antibiotic stewardship |
Inspection Report
Routine
Deficiencies: 14
Date: Feb 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including care planning, medication administration, resident rights, activities, hospice care, hearing aid use, pressure ulcer care, respiratory care, pharmaceutical services, psychotropic medication use, medication storage, food safety, rehabilitation services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to conduct quarterly care conferences, improper medication administration and documentation, inadequate activity provision, failure to notify ombudsman on discharge, missed hospice visits, improper hearing aid use, inconsistent pressure ulcer care, undated respiratory equipment, expired medications and supplies, improper psychotropic medication management, unsafe food storage and sanitation, incomplete rehabilitation services during COVID-19 isolation, and lapses in infection control practices including hand hygiene and Legionella risk management.
Deficiencies (14)
Failure to conduct quarterly care conference for Resident 14 after 9/20/22.
Medication (hydrocortisone cream 1%) left at bedside for Resident 736 who was not a candidate for self-administration.
Failure to notify Long-Term Care Ombudsman of Resident 28's discharge.
Failure to provide individualized and ongoing activity program and TV remote controls for Residents 2 and 11.
Failure to communicate with hospice agency and missed hospice visits for Resident 10 during COVID-19 isolation.
Failure to ensure Resident 10's hearing aids were applied as ordered and monitored.
Failure to ensure low air loss mattress setting was adjusted appropriately for Resident 17.
Failure to date nasal cannula tubing for Resident 538 receiving oxygen therapy.
Pharmaceutical service failures including mismatched controlled drug record and MAR for Resident 18, improper administration of chewable aspirin for Resident 12, and simultaneous administration of ferrous sulfate and calcium for Resident 7.
Failure to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications for Residents 2, 21, 30, and 537; inaccurate documentation of behavior monitoring.
Failure to store medications and supplies according to manufacturer recommendations including expired insulin pen, expired IV supplies, and unsecured A&D ointment.
Failure to provide RNA rehabilitation services for Resident 30 during COVID-19 isolation.
Multiple food safety violations including expired food items, unlabeled and undated food, unclean kitchen equipment, chipped dishware, expired sanitizer test strips, and improper backflow prevention in kitchen plumbing.
Failure to maintain infection prevention and control program including lack of Legionella risk assessment and testing, improper hand hygiene and glove use during wound care, failure to monitor COVID-19 positive resident every four hours, and failure to disinfect insulin vial tops.
Report Facts
Deficiencies cited: 14
Resident count: 32
Expired IV supplies: 49
Episodes of anxiety: 17
Episodes of poor oral intake: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Named in findings related to medication storage, wound care, and pressure ulcer care |
| LVN 1 | Licensed Vocational Nurse | Named in findings related to medication administration and expired supplies |
| DON | Director of Nursing | Named in multiple interviews verifying findings and policies |
| SSD | Social Services Director | Named in interviews related to care conferences and discharge notification |
| Activity Director | Named in findings related to activity provision | |
| CNA 1 | Certified Nursing Assistant | Named in wound care observation |
| MDS/Case Management Director | Named in interview regarding rehabilitation services | |
| Maintenance Supervisor | Named in interview regarding kitchen plumbing | |
| Director of Dietary Services | Named in interview regarding kitchen sanitation | |
| LVN 2 | Licensed Vocational Nurse | Named in medication administration and hearing aid application |
| LVN 3 | Licensed Vocational Nurse | Named in interview regarding psychotropic medication monitoring |
| RNA 2 | Rehabilitation Nurse Assistant | Named in interview regarding rehabilitation services |
Report
October 14, 2025
Report
August 26, 2025
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July 9, 2025
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July 26, 2024
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September 8, 2023
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August 14, 2023
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March 23, 2023
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September 21, 2022
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July 18, 2022
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July 7, 2022
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May 9, 2022
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April 25, 2022
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December 16, 2021
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December 16, 2021
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October 22, 2021
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