Freedom Plaza Care Center

In the surveyor’s words

From the most serious findings on record at Freedom Plaza Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF658Nov 12, 2021

  Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure a scheduled blood pressure medication was consistently administered to one resident (#5). The sample size was 5. The deficient practice could result in medications not being administered to residents. Findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a medication administration observation conducted on November 10, 2021 at 8:53 a.m. with a Registered Nurse (RN/staff #35), the RN stated that she had not received [MEDICATION(S)] (antihypertensive) ER (extended release) tablet from the pharmacy for resident #5. […]

• No harm, potential for more than minimal, patternF880Nov 12, 2021

  Based on observations, staff interviews, facility documentation, and review of policies and procedures, the facility failed to ensure that two staff members (#22 and #73) completed COVID-19 screening prior to or at the beginning of their shift, and the facility failed to ensure that staff performed appropriate hand hygiene during meal service. The census was 39. The deficient practice could result in the spread of infection. Findings include: Regarding staff COVID-19 screening: -Review of the time sheet for staff #22, a server, from October 25, 2021 through November 7, 2021 revealed that the staff member worked October 25, 26, 27, and 31, 2021; and November 1, 2, 3, 4, and 7, 2021. […]

• No harm, potential for more than minimal, patternF885Nov 12, 2021

  Based on clinical record reviews, facility documentation, staff interview, policy review, the Centers for Disease Control and Prevention (CDC) guidance, and the Centers for Medicare and Medicaid Services (CMS) Interim Final Rule, the facility failed to ensure three residents (#2, #9, and #10), their representatives, and families were informed of new COVID-19 cases occurring in the facility within the required time frame. The deficient practice would result in residents, their representatives and families not being aware of new COVID-19 cases and the actions implemented to reduce the risk of transmission. The census was 39. Findings include: Review of documentation provided by the facility included the five most recent confirmed COVID-19 cases in the facility were staff members. […]

• No harm, potential for more than minimal, isolatedF804Aug 28, 2026

  Based on observation, interviews, clinical record review and review of facility policy and procedures, the facility failed to ensure pureed foods were prepared in accordance with established recipes and preparation procedures to achieve the prescribed consistency. This deficient practice had the potential to affect residents requiring therapeutic and/or texture-modified diets by increasing the risk of receiving food inconsistent with their prescribed diet and increasing the risk of choking and/or aspiration.Findings include: An interview was conducted with the complainant on August 26, 2026, at 9:03 a.m. The complainant stated the facility was not following the approved menus, designated scoop sizes, or recipes. […]

• No harm, potential for more than minimal, isolatedF805Aug 28, 2026

  Based on observation, interviews, clinical record review and review of facility policy and procedures, the facility failed to ensure one out of two sampled residents (Resident #26) received meal consistent with the prescribed diet order. The deficient practice resulted in the resident consuming food that was not consistent with the prescribed diet and placed the resident at risk for complications associated with receiving food that did not meet the resident's individual dietary needs.Findings Include:Resident #26 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of cardia, aftercare following surgery for neoplasm, encounter for surgical aftercare following surgery on the digestive system, encounter for attention to other artificial openings of digestive… […]