Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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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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 | — | 0 | 0 |
| Aperion Care Vincennes | 14.3 mi | — | 21 | 0 |
| Prairie Village Nursing And Rehabilitation | 16.2 mi | — | 0 | 0 |
| Hillside Manor Nursing Home | 16.8 mi | — | 30 | 1 |
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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 August 2026) and official state health department websites.