The Inn at Freedom Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were administered and assessments were completed in accordance with physician orders for 3 of 12 residents (Resident #11, #47, and #48), reviewed for nursing professional standards of practice.Findings:Resident #11 (R11)Review of an admission Record revealed R11 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure.Review of R11's Order Summary dated 2/16/26 revealed, cloNIDine HCl Oral Tablet 0.1 MG Give 1 tablet by mouth three times a day.HOLD IF SBP (systolic blood pressure [top number]) LESS THAN 110. To be administered at 8:00 AM, 2:00 PM, and 8:00 PM.Review of R11's Blood Pressure Summary revealed:On 2/17/26 R11's Blood Pressure (BP) was assessed at 7:22 AM with a result of 152/77. R11's BP was not assessed again prior to the 2:00 PM clonidine administration.On 2/25/26 R11's BP was assessed at 7:35 AM with a result of 157/75. R11's BP was not assessed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the failed to maintain the kitchen/facilities equipment and fixtures in proper working order potentially affecting all residents that receive food from the kitchen. Findings include: The following observations were observed on 01/28/25 from 9:15 AM to 10:25 AM, during the initial tour of the kitchen/facility with Dining Manager (DM) A and Kitchen Supervisor (KS) B. Observation of the paper towel dispenser located above the hand sink (on the wall closest to the hood system) was out of paper towels. Review of the FDA 2017 Food Code Section, 6-301.12 Hand Drying Provision. Reflects the following, Each HANDWASHING SINK or group of adjacent HANDWASHING SINKS shall be provided with: (A.) Individual, disposable towels; . Observation of the inside of the True Refrigerator Unit revealed a build-up of food residue, debris and grime on the sides, bottom, and door seal. Review of the FDA 2017 Food Code Section, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document vital signs before witholding a medication with parameters ordered for 1 resident (Resident #83) out of 12 residents reviewed for professional standards. Findings: Resident #83 (R83) Review of an admission Record indicates R83 admitted to the facility with diagnoses that included hypertensive (high blood pressure) chronic kidney disease, supraventricular tachycardia (an irregular heart rhythm), and nonrheumatic mitral valve insufficiency (a condition affecting blood flow in the heart). Review of the January 2025 Medication Administration Record (MAR) reflected an order for Midodrine HCl Oral Tablet 5 MG (milligram) Give 2 tablets by mouth two times a day for low blood pressures Hold if SBP (systolic blood pressure) is more than >140 -Start Date- 01/28/2025 0800 (8:00 AM). The document reflected R83 did NOT receive a dose of the prescribed medication on 1/28/25 at 8:00 AM or 5:00 PM as evidenced by a 4 in the dose record which indicates Vital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to implement its Hot Liquid Protocol for one resident (Resident #85) at risk for injury from hot liquids, out of 2 residents reviewed for accidents. Findings: Resident #85 (R85) Review of an admission Record reflected R85 admitted to the facility from a hospital for rehabilitation. Review of a Hot Liquid Safety Data Collection dated 1/27/2025 reflected R85 had observed tremors in upper extremities and weakness/paresis in upper extremities which placed R85 at risk for hot liquid injuries. Review of a Care Plan initiated on 1/27/2025 indicated R85 was at risk for hot liquid injury. Interventions identified to prevent hot liquid injuries included Assist resident with hot liquids; (R85) to use cup with lid; (R85) to use splint for wrist stability; (R85) to wear clothing/lap protector; Encourage resident to drink hot liquids while sitting at the table. During an observation on 1/28/2025 at 1:52 PM, R85 was given a cup of coffee by a dietary aide. R85 had removed the lid and was drinking the coffee with a straw while…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to perform a facility-wide assessment to identify and determine the necessary resources to provide competent care for its residents, resulting in inadequate knowledge of the facility population and inadequate resources to care for residents and unmet care needs potentially affecting all 19 residents of the facility. Findings include: During the Entrance Conference interview conducted at the start of the annual recertification survey on 2/20/24 at 9:27 a.m., Information Needed from Facility Within Four Hours of Entrance was reviewed and included a request for the Facility Assessment. The facility assessment was not provided to the survey team prior to the end of the first day of the survey. The Nursing Home Administrator (NHA) submitted a facility assessment for review on 2/21/24 at 9:30 AM. The Facility Assessment Tool was dated 2/21/24 and had not been reviewed by the QAPI (Quality Assurance Process Improvement) committee for approval. Any record of a previous Facility Assessment was requested from the staff member E on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement an effective and current system of surveillance of staff and resident illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, resulting in the potential for an outbreak to go undetected. Findings: On 2/20/24 at 2:35 PM the last 3 months of infection surveillance/tracking for staff and residents was requested. Review of the resident illness tracking revealed a spreadsheet of residents that were prescribed antibiotics. There was a line list for residents that had tested positive for COVID. There was no other illness tracking for residents not prescribed antibiotics but had symptoms of infection (respiratory, integumentary, gastrointestinal, genitourinary, etc.) Review of the documentation received regarding employee illness tracking revealed Call-In Sheets and a line list for employees that had tested positive for COVID. The Call-In Sheets were not all thoroughly completed. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed follow professional standards of nursing practice for medication administration for 1 resident (Resident #226) out of 8 residents reviewed, resulting in a medication error (incorrect dose of medication administered). Findings: Resident #226 (R226) Review of an admission Record revealed R226 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: polyneuropathy (nerve pain). Review of R226's Order Summary revealed: *Gabapentin Oral Capsule 300 MG (Gabapentin) Give 1 capsule by mouth in the morning related to POLYNEUROPATHY (start date 2/10/24). *Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth at bedtime related to POLYNEUROPATHY (start date 2/11/24). Review of R226's Controlled Substances Proof of Use form for the evening gabapentin (600mg) administration revealed that on 2/12/24 the gabapentin was not signed out/administered but was documented as administered in the electronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #10 (R10) Review of an admission Record reflected R10 admitted to the facility on [DATE] with diagnoses that included a muscle weakness and gastro-esophageal reflux disease without esophagitis (GERD). Review of an annual Minimum Data Set (MDS) assessment dated [DATE] reflected R10 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. During an interview on 2/20/24 at 11:00 AM, R10 reported that she took her meals in her room and the hot food selections were not very warm. R10 also reported that the meat selections were not very tender and she would often order chicken rather than beef or pork because of this. Based on observation, interview and record review, the facility failed to provide food served at a palatable temperature for 3 of 19 residents (Resident #10, #14 and #225) reviewed for dining, resulting in dissatisfaction with the food served and the potential for decreased intake and weight loss. Findings Include: During an interview with Dietary Aide G,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat 1 of 3 residents (R1) with respect and dignity and care for the resident in a manner that promotes maintenance or enhancement of his or her quality of life, resulting in R1 being treated in a disrespectful and undignified manner that caused embarrassment, fear, and/or emotional distress. Findings include: A review off the facility's Resident Rights policy, revised December 2016, revealed, Employees shall treat all residents with kindness, respect, and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation . e. self-determination . A review of R1's admission Record, dated 8/9/23, revealed R1 was a [AGE] year-old resident admitted to the facility on [DATE] and re-admitted on [DATE]. In addition, R1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 3 residents (R1), resulting in incomplete medical records and inaccurate medical records; the potential for providers not having an accurate and complete picture of the resident's stay at the facility; and for providers not being aware of possible changes to the resident's mental, emotional, and/or physical well-being. Findings include: Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice . Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.