Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Freeman Nursing & Rehabilitation Community during CMS and state inspections, most recent first.
Failure to recognize a resident’s CHF-related change in condition led to rehospitalization. The resident had steadily increasing weights, edema, and SOB, with a BNP of 32,600 pg/ml before transfer to the ER for fluid volume overload and acute respiratory failure. The care plan lacked fluid-overload monitoring interventions such as daily weights and edema checks, and the DON acknowledged the resident had consistently gained weight.
Failure to perform hand hygiene during meal delivery. A CNA delivered multiple meal trays in the dining room without using ABHR or washing hands between tray deliveries, touched residents' silverware, handled wheelchair grips, obtained a drink from the beverage cart, and then began feeding a resident without hand hygiene. The NHA acknowledged the CNA did not perform hand hygiene during meal delivery.
Advance directive documentation and review were not completed for two residents. One resident’s DNR status was documented, but the quarterly review section showed no evidence that the care directive had been reviewed with the resident or representative. Another resident was also DNR, but the EMR lacked a signed form showing the resident had been informed of the right to formulate advance directives or state wishes in the event of incapacity. The DON could not locate current review documentation, and the Social Services Designee stated she did not track advance directive reviews.
The facility failed to provide dignified and respectful care to several residents, with reports of CNA A being mean, yelling, and treating residents roughly. One resident experienced long waits for bathroom assistance, causing distress. Multiple residents expressed dissatisfaction and fear of mistreatment due to CNA A's behavior.
A resident with intact cognition reported to a CNA that another CNA had inappropriately touched her, causing pain. Despite the report being made to a nurse four days prior, the allegation was not reported to the State Agency as required by the facility's policy. The resident also described verbal abuse and expressed distrust in the facility's administration. The NHA was aware of the incident but did not report it, violating the policy that mandates immediate reporting of abuse allegations.
A resident with intact cognition reported inappropriate physical contact by a CNA, but the facility failed to initiate a timely investigation. The resident informed another CNA, who reported the incident to a nurse four days prior, yet the NHA had not begun an investigation, despite being aware of rumors. This inaction violated the facility's policy requiring immediate investigation of abuse allegations.
A facility failed to conduct a gradual dose reduction (GDR) for an antidepressant, Lexapro, for a resident with anxiety and depression. Despite a pharmacy recommendation for dose reduction due to stable moods and no depression symptoms, the physician declined, citing potential clinical decline. The physician was unaware of the facility's GDR policy, which requires attempts within the first year of admission on a psychotropic medication. The resident continued receiving the same dosage, contrary to policy.
A facility failed to ensure a resident's DPOA understood a binding arbitration agreement. The resident, with severe cognitive impairment, signed the agreement despite lacking decision-making capacity as determined by two physicians. The agreement was not revisited when the DPOA was activated, as acknowledged by the Social Services Designee.
A resident with a thoracic wound experienced improper infection control practices during wound care. The wound dressing was observed to be saturated and leaking, and a nurse placed clean gloves on a dirty overbed table without disinfecting it. The nurse also failed to change gloves and perform hand hygiene before continuing care. The facility lacked a PRN order for dressing changes when the dressing was saturated, which was acknowledged by the DON as a problem.
A resident experienced discomfort due to an under-inflated mattress and missing drawer in their room. Despite complaints, the facility staff did not promptly address the issues. The mattress was improperly used, as staff were unaware of its operation, leading to the deficiency noted by surveyors.
Failure to Recognize CHF-Related Weight Gain and Fluid Overload
Penalty
Summary
The facility failed to recognize and respond to a change in condition for a resident with a history of CHF, hypertension, and a right femur fracture. After admission to the facility, the resident’s recorded weights increased from 139.2 pounds to 151.4 pounds over a short period, including an 8.8-pound gain since admission and a 7-pound gain in 7 days. Progress notes documented weight gain, anxiety about the weight increase, 3+ pitting edema to both lower extremities, and shortness of breath during conversation. The resident’s condition continued to worsen with ongoing shortness of breath, including feeling SOB and breathing rapidly at times, SOB especially with exertion, and +2 edema in both lower legs before transfer to the ER. A BNP lab ordered on 11/13/25 and drawn on 11/18/25 showed a value of 32,600 pg/ml. The resident was later hospitalized for fluid volume overload and acute respiratory failure secondary to exacerbation of acute congestive heart failure, and was treated with an IV diuretic drip, an indwelling catheter, salt diet restrictions, fluid restrictions, and daily weights. The resident stated that the food at the facility was salty and that she requested no salt added to her tray and avoided gravy because of its salt content. Review of the care plan showed a problem related to CHF and hypertension, but it lacked interventions to monitor for fluid volume overload such as daily weights or assessment for edema. The DON stated that the resident had consistently gained weight and acknowledged that daily weights should have been done, while the resident also reported that nursing staff did not consistently listen to her lungs or assess edema every day.
Failure to Perform Hand Hygiene During Meal Delivery
Penalty
Summary
The facility failed to perform hand hygiene during meal delivery in the dining room. During an observation on 12/10/25 at 9:06 a.m., CNA A retrieved a tray from the food cart and delivered it to a resident, then returned to the food cart and delivered additional trays to residents in the dining room without using ABHR or washing hands between tray deliveries. The report states this occurred as CNA A continued delivering two more trays of food to residents without hand hygiene. During an observation on 12/11/25 at 1:06 p.m., CNA A delivered a tray of food to a resident and used the resident's silverware to cut up a baked potato, then obtained another tray and again used the resident's silverware to cut up the baked potato. CNA A also obtained a drink from the beverage cart, retrieved another tray from the food cart, touched the handles of a wheelchair and moved a resident, continued delivering two more trays, touched another wheelchair, and then sat next to a resident and began feeding the resident without using ABHR between these tasks. The facility's NHA acknowledged that the CNA did not perform hand hygiene during meal delivery in the dining room.
Advance Directive Documentation and Review Not Completed
Penalty
Summary
The facility failed to ensure advance directives were reviewed in a timely manner for one resident and failed to ensure advance directive documentation was completed upon admission for another resident. One resident was designated as DNR, and the record showed a Medical Treatment Decisions form signed by the resident on 8/15/2024 stating the resident had been informed of the right to accept or refuse treatment and to formulate and issue advance directives. However, the quarterly review section of the form contained no documentation that the care or advance directive had been reviewed with the resident or the resident representative since the form was originally signed. A second resident was also designated as DNR, but the electronic medical record contained no signed document showing the resident had been informed of the right to formulate care or advance directives or to designate wishes in the event of incapacity. During interviews, the Social Services Designee stated she did not track review of resident care or advance directives and that nursing staff were responsible for ensuring the resident care choices were reviewed. The DON later reported she could not locate current documentation showing either resident's care directives had been reviewed.
Failure to Provide Dignified and Respectful Care
Penalty
Summary
The facility failed to ensure dignified and respectful care for four residents, leading to dissatisfaction, frustration, and fear of mistreatment. Resident R15, with intact cognition, reported being told by CNA A that she was not a priority for care, and described CNA A as mean and yelling in her face. Another resident, R24, also with intact cognition, described CNA A as treating them roughly and yelling when in a bad mood. Both residents expressed a desire for CNA A not to be involved in their care. Resident R131, a new admission for short-term rehabilitation, reported having to wait excessively long times to use the bathroom, causing physical discomfort and emotional distress. CNA C corroborated these issues, stating that CNA A had a negative demeanor and had been reported multiple times for disrespectful behavior. Resident R17 also expressed concerns about CNA A's rudeness and inappropriate behavior, including turning off the call light and walking away. These incidents highlight a pattern of undignified care and disrespectful treatment by CNA A, affecting multiple residents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse to the State Agency for one resident, identified as R15, who was reviewed for abuse. R15, who had intact cognition as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status, reported to a Certified Nurse Aide (CNA B) that another CNA (CNA A) had poked her vaginal area with a gloved finger, causing pain. R15 expressed concerns about the potential for similar abuse occurring to other residents who might not be aware of it. Despite R15's report to CNA B, who informed a nurse four days prior, the allegation was not reported to the State Agency as required by the facility's Abuse Prevention Program Policy. During interviews, R15 further described mistreatment by CNA A, including verbal abuse and inappropriate physical contact. R15 expressed a lack of trust in the facility's administration, stating that she no longer reported issues to the Director of Nursing because she felt no action would be taken. The Nursing Home Administrator (NHA) acknowledged hearing about the incident but did not report it to the State Agency. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made, which was not adhered to in this case.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to timely and fully investigate an allegation of abuse involving a resident, identified as R15, who reported an incident of inappropriate physical contact by a Certified Nurse Aide (CNA). R15, who was assessed to have intact cognition, reported to another CNA, identified as CNA B, that CNA A had poked her vaginal area with a gloved finger, causing discomfort. This report was made to CNA B four days prior to the surveyor's interview, but the facility had not initiated an investigation into the allegation. During the survey, the Nursing Home Administrator (NHA) acknowledged hearing rumors about the incident but had not taken any steps to investigate the matter. The facility's Abuse Prevention Program Policy & Procedure mandates that investigations into abuse allegations be initiated immediately and completed within five days, including interviews with all involved parties. However, the NHA admitted to being unaware of any specific details or grievances related to CNA A's treatment of residents, indicating a failure to adhere to the facility's policy and procedure for handling abuse allegations.
Failure to Conduct Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to appropriately conduct a gradual dose reduction (GDR) for an antidepressant medication, Lexapro, for a resident with diagnoses including anxiety disorder, depression, and adult failure to thrive. The resident had been receiving Lexapro 10 mg daily since September 2022, and a consultation report from the pharmacy in September 2024 recommended a dose reduction due to stable moods and behaviors and the absence of depression symptoms. Despite this recommendation, the physician declined the dose reduction, citing concerns about potential clinical decline, and the resident continued to receive the same dosage. The physician was unaware of the facility's policy regarding GDRs, which requires an attempt at dose reduction within the first year of admission on a psychotropic medication. The Director of Nursing confirmed that the resident should have had an attempted GDR and planned to discuss the policy with the physician. The facility's policy mandates that a GDR be attempted in two separate quarters within the first year of a resident being on a psychotropic medication, which was not adhered to in this case.
Failure to Ensure DPOA Understood Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident's Durable Power of Attorney (DPOA) understood the purpose of binding arbitration agreements. This deficiency was identified for a resident who was admitted with diagnoses including anxiety disorder, depression, and hypertension, and who scored 6 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating severe cognitive impairment. Despite this, the resident signed an arbitration agreement. A subsequent review of the facility's documentation revealed that the resident was determined by two physicians to lack the capacity to make reasoned medical decisions, with signatures obtained on two separate dates. However, the arbitration agreement was not revisited when the resident's incapacity was determined, and the DPOA was activated. During an interview, the Social Services Designee acknowledged that the agreement was not revisited under these circumstances.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care for a resident with a thoracic wound. On two separate occasions, the resident's wound dressing was observed to be improperly sealed and saturated with drainage, which had leaked onto the resident's clothing. During wound care, a nurse placed clean gloves on a dirty overbed table without disinfecting it and attempted to continue wound care without changing gloves or performing hand hygiene. The nurse was reminded by the surveyor to change gloves and perform hand hygiene before proceeding. The resident's physician orders required daily dressing changes, but there was no PRN order for changing the dressing if it became saturated or leaked. The Director of Nursing acknowledged the lack of a PRN order and confirmed that it would be standard practice to change a dressing if it was fully saturated and leaking. The facility's failure to adhere to proper hand hygiene and glove use, as outlined by the CDC guidelines, contributed to the potential spread of infection.
Deficiency in Mattress and Furniture Provision
Penalty
Summary
The facility failed to provide a comfortable mattress and functional furniture for a resident, leading to a deficiency in care. The resident, who had intact cognition and was able to communicate her needs, reported discomfort due to an under-inflated mattress. Despite her complaints, the facility staff did not address the issue promptly. The mattress was described as having no air in the middle section, causing the resident to lie on the springs, which was painful. The Director of Nursing and other staff members acknowledged the problem but did not take immediate action to resolve it. Additionally, the resident's room was missing a drawer from the built-in shelving unit, which left her clothing exposed. The resident mentioned that the drawer had been taken for someone else and had been missing for a long time. This lack of functional furniture contributed to the deficiency in providing adequate living conditions for the resident. The mattress manufacturer confirmed that the mattress was delivered to the facility but was not properly inflated, as it required periodic adjustments. The facility staff, including the Maintenance Director, were unaware of how to operate the mattress, leading to its improper use. The manufacturer's instructions emphasized the importance of checking the mattress daily for proper inflation, which was not adhered to by the facility, resulting in the resident's discomfort and the deficiency noted by the surveyors.
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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 Kingsford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health And Rehabilitation Of Kingsford | 0.6 mi | ★★★★★ | 4 | 0 |
| Maryhill Manor | 4.7 mi | ★★★★★ | 7 | 0 |
| Florence Health Services | 11.3 mi | ★★★★★ | 28 | 0 |
| Iron County Medical Care Facility | 24.1 mi | ★★★★★ | 0 | 0 |
| Pinecrest Medical Care Facility | 28.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.