Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Freeman Nursing & Rehabilitation Community during CMS and state inspections, most recent first.
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 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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | — | 2 | 0 |
| Maryhill Manor | 4.7 mi | — | 7 | 0 |
| Florence Health Services | 11.3 mi | — | 7 | 0 |
| Iron County Medical Care Facility | 24.1 mi | — | 0 | 0 |
| Pinecrest Medical Care Facility | 28.8 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Freeman Nursing & Rehabilitation Community.
100% money-back within 48 hours.
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.