Cycle 1
Health 2024-07-18 · Fire 2024-07-18
9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Bradenton, FL
Inn At Freedom Village, The
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
6410 21st Ave W, Bradenton, FL
(941) 798-8300
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Healthpeak Properties, Inc.
Operator or chain grouping
Approved since
1989-06-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.01
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.46
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
3.16
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
5.63
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.47
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.84
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
5.54
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,643
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9840
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.93% · Performance 22.55% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1
Baseline 5.08% · Performance 7.54% · Measure score 1 · Achievement 1 · Improvement 0
Total nurse turnover
3.45
Baseline 57.48% · Performance 49.59% · Measure score 3.45 · Achievement 3.45 · Improvement 1.92
Adjusted total nurse staffing
6
Baseline 4.90 hours · Performance 4.79 hours · Measure score 6 · Achievement 6 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.91% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 455 · Observed rate 6.59% · Lower 95% interval 6.7% |
| Discharge to community | 44.35% |
50.57%
6.2 pts worse
|
Worse than the National Rate · Eligible stays 433 · Observed rate 41.11% · Lower 95% interval 39.18% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.36% |
95.27%
4.1 pts better
|
Numerator 312 · Denominator 314 |
| Falls with major injury | 1.27% |
0.77%
0.5 pts worse
|
Numerator 4 · Denominator 314 |
| Discharge self-care score | 49.21% |
53.69%
4.5 pts worse
|
Numerator 94 · Denominator 191 |
| Discharge mobility score | 34.55% |
50.94%
16.4 pts worse
|
Numerator 66 · Denominator 191 |
| Pressure ulcers or injuries, new or worsened | 0.32% |
2.29%
2 pts better
|
Numerator 1 · Denominator 314 · Adjusted rate 0.33% |
| Healthcare-associated infections requiring hospitalization | 7.53% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 278 · Observed rate 6.47% · Lower 95% interval 4.99% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 124 |
| Staff flu vaccination coverage | 3.8% |
42%
38.2 pts worse
|
Numerator 6 · Denominator 158 |
| Discharge function score | 31.94% |
56.45%
24.5 pts worse
|
Numerator 61 · Denominator 191 |
| Transfer of health information to provider | 92.65% |
95.95%
3.3 pts worse
|
Numerator 63 · Denominator 68 |
| Transfer of health information to patient | 92.41% |
96.28%
3.9 pts worse
|
Numerator 207 · Denominator 224 |
| Resident COVID-19 vaccinations up to date | 18.62% |
25.2%
6.6 pts worse
|
Numerator 27 · Denominator 145 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 3.6 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
97.8%
0.7 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.0% · Q3 96.8% · Q4 100.0% · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
2.6%
3.4 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 6.1% · Q3 6.5% · Q4 9.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
3.7%
1 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 3.6% · Q4 4.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
5.9%
0.5 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 11.1% · Q3 7.1% · Q4 0.0% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.4% |
15.7%
5.7 pts worse
|
19.6%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 20.7% · Q3 17.2% · Q4 31.0% · 4Q avg 21.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.3% |
9.8%
2.5 pts better
|
16.7%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.0% · Q3 4.3% · Q4 10.0% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.1% |
11.7%
7.6 pts better
|
16.3%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
9.8%
2 pts worse
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 11.5% · Q3 7.4% · Q4 14.8% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.4%
1.6 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
0.8%
1.6 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.2% · Q3 3.3% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
12.5%
13.8 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.0% · Q2 20.6% · Q3 20.3% · Q4 15.5% · 4Q avg 26.3% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
5.1%
1.4 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 4.8% · Q3 2.4% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
94.3%
5.2 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.3% · Q3 99.8% · Q4 99.7% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
9.3%
1.6 pts worse
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 9.9% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.1% · Q3 1.0% · Q4 1.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
94.7%
0.4 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
26.2%
1.3 pts better
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 21.9% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-19 · Fire 2022-05-19
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-02-12 · Fire 2021-02-12
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-18
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2024-08-17
D · Potential for more than minimal harm
2024-07-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-16
D · Potential for more than minimal harm
2021-02-12
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-03-25
D · Potential for more than minimal harm
2021-02-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-03-25
D · Potential for more than minimal harm
2021-02-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-03-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-07-18
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-08-16
E · Potential for more than minimal harm
2024-07-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-08-16
E · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-08-16
D · Potential for more than minimal harm
2022-05-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-06-19
D · Potential for more than minimal harm
2022-05-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-19
D · Potential for more than minimal harm
2021-02-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-03-12
D · Potential for more than minimal harm
2021-02-12
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-03-12
D · Potential for more than minimal harm
2021-02-12
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2021-03-12
D · Potential for more than minimal harm
2021-02-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-03-12
Penalties and ownership
What sits behind the stars
Ownership
Ccrc Opco Ventures LLC
5% Or Greater Direct Ownership Interest · Organization
Ccrc Propco - Bradenton, LLC
5% Or Greater Security Interest · Organization
Ccrc Propco Ventures, LLC
5% Or Greater Indirect Ownership Interest · Organization
Haider, Joseph
Operational/Managerial Control · Individual
Hcp S-H 2014 Member LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Op, LLC
5% Or Greater Indirect Ownership Interest · Organization
Healthpeak Properties Inc
5% Or Greater Indirect Ownership Interest · Organization
Levato, Steven
Operational/Managerial Control · Individual
Life Care Services LLC
Operational/Managerial Control · Organization
Mcalister, Scott
Operational/Managerial Control · Individual
S-H 2014 Opco Trs Inc
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Casa Mora Rehabilitation And Extended Care
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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $73,220 in total fines with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Heritage Park Health Center By Harborview
Bradenton, FL
3-star overall rating with 3-star inspections with $4,475 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Surrey Place Healthcare And Rehabilitation
Bradenton, FL
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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