Freeman Nursing & Rehabilitation Community

In the surveyor’s words

From the most serious findings on record at Freeman Nursing & Rehabilitation Community, in the surveyor’s own words.

• Actual harm, isolatedF684Dec 11, 2025

  Based on observation, interview, and record review the facility failed to recognize a change in condition for one Resident (Resident #2) of one resident reviewed for hospitalization. This deficient practice resulted in rehospitalization, insertion of an indwelling catheter, and intravenous diuretic therapy.(All times are recorded in Eastern Standard Time unless otherwise indicated.)Findings include:Resident #2 (R2)On 12/9/25 at 12:53 PM, an interview was conducted with R2 in their room while sitting in their recliner. R2 was asked if they had a recent hospitalization and replied, Yes, I needed diuretics because of having too much fluid on me. They even put a catheter in me because I was peeing so much. The food here is so salty. […]

• Actual harm, isolatedF600Dec 5, 2022

  This citation pertains to Intake #MI00132859. All times are Eastern Standard Time (EST) unless otherwise noted. Based on observation, interview, and record review, the facility failed to prevent verbal abuse for two Residents (#21 and #25) of nine residents reviewed for abuse during resident to resident incidents. This deficient practice resulted in psychosocial harm for Resident #21, with feelings of fear, helplessness, and vulnerability. Findings include: Review of Resident #21's Minimum Data Set (MDS) assessment, dated 06/20/22, revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including paraplegia (paralysis of lower extremities), pressure ulcer, kidney disease, anxiety, and depression. […]

• Actual harm, isolatedF684Sep 29, 2022

  Based on observation, interview and record review, the facility failed to identify and monitor a change of condition and follow the care plan regarding catheter secure device, for one Resident (#1), from three reviewed for change in condition. This deficient practice resulted in a urinary tract infection, with [CONDITION(S)] (a life threatening blood infection), endocarditis (a life threatening heart valve infection caused by [CONDITION(S)]) and necrotic (dead) untreatable toes, with admission to the hospital, and resultant end of life comfort care. […]

• Actual harm, isolatedF686Sep 29, 2022

  Based on observation, interview and record review, the facility failed to assess and treat pressure ulcers for one Resident (#6) from three reviewed for pressure ulcers. This deficient practice resulted in the worsening of the Resident's pressure ulcers to stage 4 with hospitalization , a wound vac system and pain. Findings include: During an interview on 9/28/22 at 3:46 p.m., Registered Nurse, (RN) A confirmed Resident #6 returned from the hospital on 9/27/22 with wound clinic orders for wounds to both hip wounds and two wounds to the back that had a wound vac system in place. RN A said the pharmacy did not yet have the ordered medication, but it would arrive the following day. […]

• Actual harm, isolatedF689Sep 29, 2022

  Based on observation, interview and record review, the facility failed to implement appropriate interventions to prevent falls for three Residents (#1, #2 and #4) from three reviewed for falls. This deficient practice resulted in a fracture of the pinky finger for Resident #2, a fracture of the left arm for Resident #4 and a fall with hospitalization for Resident #1. Findings include: Resident #1 According to electronic medical record (EMR), Resident #1 was admitted to the facility on [DATE], with dementia, hearing loss, urine retention with long term use catheter, high blood pressure, hand contractures, acute kidney failure, history of falls, weakness and unsteady gait. An Event Report, dated 8/7/22 revealed Resident #1 fell from bed when he rolled over. […]