Freedom Village Healthcare Center
Inspection Findings
F-Tag F0692
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 3) received the appropriate services needed to maintain optimal nutritional status. * The facility failed to timely notify Resident 3's physician of the RD recommendations when Resident 3 had a weight loss of 6 pounds in six days. This failure had the potential for the resident to not receive the necessary care and intervention timely to maintain the resident's nutrition status and/or prevent further weight loss.Findings: Review of the facility's P&P titled Weight Management (undated) showed the residents' weights are monitored for undesirable or unintended weight loss or gain. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The physician and multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Review of the facility's P&P titled Weight Assessment and Intervention revised 11/16/24, showed the interdisciplinary team will strive to monitor and intervene for undesirable weight change for the residents. Medical record review for Resident 3 was initiated
on 9/19/25. Resident 3 was admitted to the facility on [DATE REDACTED]. Review of Resident 3's H&P examination dated 9/5/25, showed Resident 3 had the capacity to make medical decisions. Review of Resident 3's Weights and Vitals Summary showed Resident 3's weight was documented as follows:- dated 9/3/25, 139 lbs, and- dated 9/9/25,133 lbs, a loss of 6 lbs (4.3%) in six days compared to 9/3/25; Review of Resident 3's Nutrition assessment dated [DATE REDACTED], showed current PO (oral) intake inadequate for meeting the ENN (estimated nutrient/nutrition needs) due to variable intake. The RD assessment further showed recommend:
- 1. MVI/min (multivitamin with minerals supplement) daily, 2. snacks TID, 3. Glucerna shakes (a nutritional
supplement for individuals with diabetes) TID w/meals (with meals). Review of the facility's document titled RD Recommendations dated 9/9/25, showed the RD made the following recommendations for Resident 3:MVI/min daily;- snacks TID; and- Glucerna shakes one can with meals. Review of Resident 3's Physician Order Summary showed a physician's order dated 9/18/25, for the above RD recommendations for Resident 3, nine days after the RD had made the recommendations. On 9/25/25 at 1412 hours, a concurrent interview and medical record review for Resident 3 was conducted with LVN 1. LVN 1 verified
the nutrition assessment and recommendations were conducted by the RD on 9/9/25. LVN 1 stated she received the RD recommendation on 9/18/25, from the DON and immediately followed up with the physician to obtain the orders on the same day. LVN 1 further stated a delay in carrying out the RD recommendations and following up with the physician had the potential to put the resident at risk for more weight loss, dehydration, and poor wound healing. On 9/25/25 at 1639 hours, the DON was informed and acknowledged the above findings. The DON stated the charge nurses were responsible for ensuring the RD recommendations were relayed to the physician timely. The DON further it was an honest miss this time.
Residents Affected - Few
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
Event ID:
FREEDOM VILLAGE HEALTHCARE CENTER in LAKE FOREST, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LAKE FOREST, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FREEDOM VILLAGE HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.