FREEDOM VILLAGE HEALTHCARE CENTER
Open-data reference.
FREEDOM VILLAGE HEALTHCARE CENTER is a for profit - partnership facility in LAKE FOREST, CA with 52 certified beds and a 3-star overall CMS rating. The facility has 50 deficiency records on file.
23442 EL TORO ROAD, LAKE FOREST, CA 92630
Phone: 9494720277
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 555391
- Ownership
- For profit - Partnership
- Provider Type
- Medicare and Medicaid
- Beds
- 52
- Residents
- 40
- In Hospital
- No
- County
- Orange
- Last Inspection
- Nov 26, 2025
Staffing Data
- RN Hours
- 0.77 (nat'l avg: 0.68)
- LPN Hours
- 1.40
- CNA Hours
- 2.91
- Total Nursing Hours
- 5.07 (nat'l avg: 3.89)
- PT Hours
- 0.13
- Nursing Turnover
- 43.4%
- RN Turnover
- 57.1%
What the CMS Record Reveals About FREEDOM VILLAGE HEALTHCARE CENTER
FREEDOM VILLAGE HEALTHCARE CENTER operates 52 certified beds in LAKE FOREST, CA with approximately 40 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (4★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 50 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 5.07 total nursing hours per resident day (national average 3.89), with RN coverage at 0.77 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Partnership" ownership and operating as a "Medicare and Medicaid" provider, FREEDOM VILLAGE HEALTHCARE CENTER falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 43.4%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (50 most recent)
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Category: Infection Control Deficiencies
Corrected: Dec 18, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Dec 18, 2025
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Dec 18, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 18, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 18, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 18, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Dec 18, 2025
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Dec 18, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 18, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 18, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 18, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Category: Resident Rights Deficiencies
Corrected: Dec 18, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 18, 2025
The resident has the right to receive notices in a format and a language he or she understands.
Category: Resident Rights Deficiencies
Corrected: Dec 18, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Dec 18, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Dec 18, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 26, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jan 13, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 29, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 29, 2024
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Nov 17, 2024
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 17, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 17, 2024
Keep all essential equipment working safely.
Category: Environmental Deficiencies
Corrected: Nov 17, 2024
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Nov 17, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Nov 17, 2024
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Nov 17, 2024
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Category: Administration Deficiencies
Corrected: Nov 17, 2024
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 17, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 17, 2024
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 17, 2024
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 17, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 17, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 17, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Nov 17, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Nov 17, 2024
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 17, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Nov 17, 2024
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category: Resident Rights Deficiencies
Corrected: Nov 17, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Nov 17, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 17, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 12, 2023
Provide or get specialized rehabilitative services as required for a resident.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 12, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 12, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 12, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 12, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Mar 12, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 12, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 12, 2023
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 12, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 13.4% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 4.5% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 2.4% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.4% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 98.9% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.8% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 21.5% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 10.3% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 99.2% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 4.2% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 20.2% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 7.5% | Yes |
Penalty History
No penalties on record.
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Frequently Asked Questions
What is the overall CMS rating for FREEDOM VILLAGE HEALTHCARE CENTER?
What are the staffing levels at FREEDOM VILLAGE HEALTHCARE CENTER?
How many beds does FREEDOM VILLAGE HEALTHCARE CENTER have?
Does FREEDOM VILLAGE HEALTHCARE CENTER have any deficiencies on record?
Has FREEDOM VILLAGE HEALTHCARE CENTER received any fines or penalties?
Who owns FREEDOM VILLAGE HEALTHCARE CENTER?
When was FREEDOM VILLAGE HEALTHCARE CENTER last inspected?
What quality measures are tracked for FREEDOM VILLAGE HEALTHCARE CENTER?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.