Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Freelandville Community Home during CMS and state inspections, most recent first.
Unsanitary food and ice handling was observed during meal service. A staff member placed an individual butter packet directly on top of a resident’s plated food, and an ice scoop was seen lying in the ice used for resident drinks. The Dietary Manager stated the scoop should not have been left on the ice.
A resident who was totally dependent on staff for toileting was left waiting extended periods for bathroom assistance, with staff unsure who was assigned and one RN telling him he was "in the way" and moving him farther from his room. Another resident, dependent on staff for showers and transfers, reported pain and pinching during a Hoyer lift transfer after a shower, but the CNA continued the transfer and the resident later had a skin tear with bleeding. The DON stated residents should be helped to the bathroom within 15 minutes if possible, and the facility policy required staff to check comfort for signs of pinching or pulling during mechanical lifts.
The facility failed to notify the physician of significant changes for three residents. One resident with afib had repeated elevated HRs, including during dialysis, but the record lacked MD notification. Another resident had significant wt loss from 102.0 lbs to 90.8 lbs over 2 weeks, and the record lacked physician notification. A third resident on dialysis said dialysis made him weak and refused a dialysis access procedure, but the record lacked follow-up communication with the MD, nephrologist, resident, or resident representative.
Failure to provide proper incontinence care and treat a UTI appropriately. A resident with severe cognitive impairment and total dependence for toileting was incontinent of bowel and bladder, and during observation was found with a soiled brief and stool residue on the thigh that appeared to have been present since the prior shift. The resident was started on Cephalexin before urine culture results were available, but the culture later showed resistance to that antibiotic, and 4 doses were given before a different ABX was started.
Incomplete dialysis communication and missing post-dialysis assessment documentation were found for two residents receiving M-W-F HD. One resident with ESRD had multiple communication forms that lacked dialysis center information or post-dialysis VS, and another resident with renal dialysis dependence and a tunneled CVC had forms missing pre/post treatment details, no paperwork returned on some occasions, and no charted assessment of the access site after dialysis. RN and DON interviews confirmed the expected exchange of the communication form and documentation of the resident’s condition, VS, and access site in the clinical record.
Posted Nurse Staffing Form Missing Actual Hours Worked. The facility failed to ensure the daily nurse staffing form included the actual hours worked by RNs, LPNs, and CNAs on multiple days reviewed by surveyors. The form was observed without the required hours, and the Scheduler stated the night shift nurses completed the form and that she had not read the policy for filling it out.
The facility failed to provide adequate assistance during a mechanical lift transfer for a resident, resulting in a femur fracture. Another resident experienced multiple falls due to inadequate supervision and unsecured equipment, leading to a hip fracture. The facility did not adhere to policies requiring two staff for transfers and failed to document fall assessments and interventions.
The facility failed to ensure accurate MDS assessments, leading to discrepancies in documenting unnecessary medications and restraints. Two residents were incorrectly noted as using bed rails as restraints, while another resident's dementia diagnosis was omitted from the MDS. Additionally, a resident's use of insulin was not coded as a hypoglycemic medication. These errors highlight the facility's failure to maintain accurate assessments.
The facility did not have an RN present for the required 8 consecutive hours on two days, as confirmed by staffing records and the Administrator. A time card showed an RN was only present for part of the required time, violating the facility's policy.
The facility failed to ensure detailed reporting of incidents involving two residents, leading to deficiencies in documentation and investigation. One resident fell off the toilet due to an unsecured seat, while another fell during a transfer using a mechanical lift, resulting in a fracture. The reports lacked thorough investigation into the causes, and the CNA involved in the second incident was not adequately trained on lift use.
The facility failed to develop comprehensive care plans for two residents receiving multiple medications, including diuretics, insulin, anticoagulants, opioids, and antiplatelet medications. Despite the facility's policy requiring care plans within seven days of the MDS Assessment, the clinical records lacked necessary care plans for these medications.
Unsanitary Food and Ice Handling During Meal Service
Penalty
Summary
Food was not served in a sanitary manner during 1 of 3 dining observations. During plating of resident trays, a staff member grabbed an individual plastic butter container with a gloved hand and placed it directly on top of the food on the plate to be served to residents. At the same time, ice intended for resident drinks was observed in a metal container on a cart with the ice scoop laying in the ice. The Dietary Manager later stated that the scoop should not have been laid on the ice. A current Ice machine Policy dated 12/1/25 was also provided and included infection control language stating that infection control is important to decrease the risk of illness to residents, staff, and visitors.
Failure to Provide Timely Toileting Assistance and Respectful Transfer Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect when residents who were dependent on staff for toileting and transfers were left waiting for assistance and a resident in a Hoyer lift reported pain that was not addressed at the time. During a resident council meeting, three of 14 residents stated they had to wait longer than 15 minutes for staff help to use the bathroom. The DON stated she expected call lights to be answered and residents taken to the bathroom within 15 minutes if possible, and that 44 minutes was much longer than expected for a resident to wait to toilet. Resident 3 had diagnoses including Parkinson's disease and intellectual disability, and the most recent MDS indicated moderately impaired cognition and total dependence on staff for toileting. On 2/19/26, he indicated he needed to use the bathroom and was observed waiting with his call light on while staff discussed who was assigned to him and who could help. He remained waiting while staff walked past him, looked for help, and delayed assistance. Later that morning, he stated he needed a bowel movement and was tired of waiting after taking a laxative. He was eventually assisted with a Hoyer lift, bedpan, and skin assessment after the delay. On 2/20/26, Resident 3 again indicated he needed to use the bathroom while his call light was on. Staff told him they would help after finishing with another resident, and RN 22 told him, "you're in the way," moved him farther from his room, and walked away. Housekeeping staff also told him she could not help and pushed him back to his room before finding someone. Resident 26, who was cognitively intact and dependent on staff for showers and transfers, reported that during a Hoyer lift transfer after a shower, she told the CNA her skin was being pinched, but the CNA ignored her and continued the transfer. The resident later had bleeding from a skin tear in a fold of her right leg, and the DON stated the pad had folded in a skin fold and caused shearing during the transfer.
Failure to Notify Physician of Significant Changes in Condition
Penalty
Summary
The facility failed to ensure physician notification of changes in condition for residents receiving dialysis and for a resident with significant weight loss. For a resident with atrial fibrillation and no cognitive impairment, the record showed repeated elevated heart rates, including heart rates over 100 and irregular rhythms, along with dialysis communication forms documenting elevated pre- and post-dialysis heart rates. The record lacked notification to the physician of these increased heart rates, despite care plan interventions directing staff to monitor vital signs and report significant abnormalities and signs or symptoms of altered cardiac output. For another resident with weakness, anemia, and severe cognitive impairment, the nutritional care plan directed staff to monitor and report signs of malnutrition and significant weight loss. The resident’s weights declined from 102.0 pounds to 98.0 pounds and then to 90.8 pounds over a two-week period, and the record lacked notification to the physician of the weight loss. A later observed weight was 88.2 pounds. The DON stated the nurse should identify weight loss when entering a new weight, re-weigh if there was a 3-pound difference, and notify the physician of true weight loss. For a resident dependent on renal dialysis, the resident stated he did not like dialysis because it made him weak and later refused a scheduled procedure for dialysis access placement, stating he was not getting it done and did not need it. The record documented a secure message asking whether dialysis was still needed and a note that the resident refused the procedure, but there was no further communication or notification to the physician, nephrologist, resident, or resident representative about the request to discontinue dialysis and refusal of the port replacement appointment. The DON stated she would expect notifications and communication with providers, the resident, and family about such requests and refusals, but documentation was not provided.
Failure to Provide Proper Incontinence Care and Treat UTI Appropriately
Penalty
Summary
The facility failed to prevent and appropriately treat a urinary tract infection for a resident with Alzheimer's disease and dementia who had severe cognitive impairment and was dependent on staff for toileting, with bladder and bowel incontinence. The resident's care plan directed staff to provide pericare after each incontinence episode, and the facility policy stated that appropriate perineal hygiene should be regularly provided to residents who are incontinent of bladder and bowel. During observation, the resident was found with a liquid-soaked brief and a brown streak approximately 6 inches long behind the right thigh that CNA 10 stated had likely been there since the night shift because it was stuck to the resident's leg. The resident's urinalysis indicated a UTI, and a urine culture later showed resistance to Cephalexin. Despite this, Cephalexin was started before the culture result was available, and the Medication Administration Record showed 4 doses were given before Cefdinir was started. The Infection Preventionist stated the physician had started Cephalexin prior to the urine culture report and that the bacteria was resistant to Cephalexin, requiring a different antibiotic.
Incomplete Dialysis Communication and Missing Post-Dialysis Assessment Documentation
Penalty
Summary
The facility failed to ensure ongoing communication between the dialysis center and the facility for 2 residents receiving hemodialysis. Resident 1 had ESRD, no cognitive impairment, and an order for dialysis every Monday, Wednesday, and Friday. The dialysis communication forms in the clinical record were incomplete on multiple dates, including missing information from the dialysis center, missing post-dialysis vital signs, and one form that was brought back incomplete. Resident 2 had dependence on renal dialysis, cognitive impairment, and orders for dialysis Monday, Wednesday, and Friday, a right tunneled central venous catheter to be maintained by the dialysis center, observation of the access site twice daily for signs and symptoms of infection, and completion of the Hemodialysis Communication Form every dialysis day. The Hemodialysis Communication Forms were missing information on several dates, including forms not completed by dialysis, no paperwork returned, and a notation of n/a. The clinical record also lacked documentation that staff assessed the dialysis access site after dialysis. RN 22 stated the nurse should complete the pre-dialysis information and that the resident usually returns with the form for the dialysis center to complete post-dialysis information, while the DON stated there should be a communication form returned every time and expected documentation of the resident's condition, especially vital signs and access site, in the clinical record.
Posted Nurse Staffing Form Missing Actual Hours Worked
Penalty
Summary
The facility failed to ensure the Posted Nurse Staffing form contained the actual hours worked by the registered nurses, licensed practical nurses, and certified nurse aides for 4 of 5 days reviewed during the survey. On 2/17/26, 2/18/26, 2/19/26, and 2/20/26, surveyors observed that the Posted Nurse Staffing form lacked the actual hours worked by these staff members. During an interview on 2/20/26, the Scheduler stated that the night shift nurses filled out the Posted Nurse Staffing form. During a later interview on 2/23/26, the Scheduler stated she had not read the policy on how to complete the form. A Posted Daily Nurse Staffing Form Information policy dated 12/1/25, provided by the Business Office Manager on 2/23/26, stated that the facility would provide the required information to be posted daily, including the total number of staff and actual hours worked per shift for RNs, LPNs, and CNAs.
Inadequate Assistance and Supervision During Transfers and Falls
Penalty
Summary
The facility failed to provide adequate assistance during a mechanical lift transfer for a resident who required extensive assistance of two staff members. The incident involved a resident with Alzheimer's disease and a history of stroke, who was at high risk for falls. The mechanical lift transfer was performed by a single CNA, contrary to the facility's policy requiring two staff members. This resulted in the resident falling and sustaining a right femur fracture. The clinical record lacked documentation of a fall risk assessment between March and August, and there were no immediate interventions implemented to prevent further falls after the incident. Another deficiency involved a cognitively impaired resident who was at risk of falls. The resident experienced multiple falls, including one where they slid off a commode due to an unsecured high-rise toilet seat. This fall resulted in a right hip fracture requiring surgical repair. The facility's care plan did not include immediate interventions to prevent further falls after the incident, and there was a lack of documentation regarding assessments and interventions following subsequent falls. The facility's policies on mechanical lift use and fall prevention were not adhered to, contributing to the incidents. The mechanical lift policy required two nursing assistants for safe transfers, which was not followed. Additionally, the falls policy required documentation of fall assessments and interventions, which were not consistently recorded in the residents' medical records. The facility's failure to implement and document appropriate interventions and assessments contributed to the residents' injuries.
Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in the documentation of unnecessary medications and the use of restraints. For two residents, the MDS inaccurately indicated the use of bed rails as restraints, despite the absence of physician orders or care plans for restraints. Interviews with staff revealed that the bed rails were not used as restraints, as the residents were either immobile or used the rails for bed mobility, which does not meet the definition of a physical restraint according to the Resident Assessment Instrument (RAI) manual. Another resident's MDS assessment failed to document a diagnosis of dementia, despite the presence of care plans indicating severe cognitive impairment due to dementia. The MDS Coordinator explained that a diagnosis must be coded on the MDS if there was relevant activity in the previous seven-day look-back period. However, the resident's dementia care was managed through non-medicinal means, as per the family's wishes, and was not documented in a way that would trigger coding on the MDS. Additionally, the MDS for a resident with diabetes mellitus did not reflect the administration of hypoglycemic medications, despite physician orders and medication administration records indicating the use of insulin. The MDS Coordinator did not code insulin as a hypoglycemic medication, which contributed to the inaccuracy of the MDS assessment. These discrepancies highlight the facility's failure to maintain accurate and complete assessments, which are crucial for ensuring appropriate care and treatment for residents.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified for two specific days, November 28 and November 29, 2024. During a review of staffing records on December 9, 2024, it was found that the facility did not have an RN in the building for the required duration on these days. The Administrator confirmed during an interview that an RN was not present for the full 8 hours on the specified dates and acknowledged the expectation for an RN to be available for 8 consecutive hours daily. A time card for RN 27 showed that she was only present for 3 hours and 47 minutes on one of the days in question. The facility's current policy, dated 2001, mandates that a registered nurse provides services for at least eight consecutive hours every 24 hours, seven days a week.
Deficiencies in Incident Reporting and Investigation
Penalty
Summary
The facility failed to ensure detailed reporting of incidents involving two residents, leading to deficiencies in incident documentation and investigation. In the first case, a resident with Alzheimer's disease and anxiety fell off the toilet due to an unsecured high-rise toilet seat. The incident report noted the resident's confusion and history of fidgeting, but the reason for the riser sliding off was undetermined. The report lacked a thorough investigation into the cause of the fall, and the potential involvement of the resident's roommate was not fully explored. In the second case, a resident with Alzheimer's disease and a history of stroke fell during a transfer using a mechanical lift, resulting in a right femur fracture. The incident report indicated that the CNA involved operated the lift without a second person, contrary to facility policy. The CNA, who was certified in Tennessee but not yet in Indiana, was not adequately trained on the use of mechanical lifts at the facility. The report failed to provide a detailed account of the incident and the specific actions that led to the fall. Both incidents highlight the facility's failure to conduct comprehensive investigations and provide detailed reports to the appropriate authorities. The lack of thorough documentation and investigation into these incidents suggests a deficiency in the facility's incident reporting and response procedures, which could impact the quality of care provided to residents.
Failure to Develop Comprehensive Care Plans for Medications
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents who were administered multiple medications, including diuretics, insulin, anticoagulants, opioids, and antiplatelet medications. Resident 15, who was cognitively intact, had diagnoses including heart failure, atrial fibrillation, end-stage renal disease, and diabetes mellitus. Despite receiving medications such as Apixaban, Aspirin, Basaglar KwikPen, Furosemide, Oxycodone, and Tramadol, the clinical record lacked a care plan for antiplatelets, insulin, and opioids. Similarly, Resident 14, who had moderately impaired cognition and required substantial assistance, was receiving Furosemide for heart failure, but there was no care plan for the use of the diuretic. The Director of Nursing (DON) indicated that the MDS Coordinator and the DON were responsible for ensuring care plans were included in the clinical records. The facility's policy, dated March 2022, required that a comprehensive, person-centered care plan be developed within seven days of the completion of the required MDS Assessment and be revised as the resident's condition changes. However, the facility did not adhere to this policy, resulting in the absence of necessary care plans for the medications administered to the residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Freelandville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Village | 7.2 mi | ★★★★★ | 15 | 0 |
| Health Center At Glenburn Home | 14 mi | ★★★★★ | 4 | 0 |
| Aperion Care Vincennes | 14.3 mi | ★★★★★ | 24 | 0 |
| Prairie Village Nursing And Rehabilitation | 16.2 mi | ★★★★★ | 0 | 0 |
| Hillside Manor Nursing Home | 16.8 mi | ★★★★★ | 31 | 1 |
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