Freedom Square Health Care Center

In the surveyor’s words

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

• Actual harm, isolatedF684Feb 18, 2026

  Based on interviews and record review, the facility failed to provide treatment related to respiratory complications to one resident (#2) out of three residents sampled. On 2/10/2026 at 5:55 p.m. Resident #2 began to experience increased mucous production, increased phlegm, and coughing as a result of his illness. On 2/11/2026 at 2:35 a.m. Resident #2 was found to have no pulse and not breathing. Findings Included:An interview was conducted on 2/17/26 at 1:07 p.m. with the Resident Representative (RR) for Resident #2. The RR stated having had several conversations with the facility nursing staff regarding Resident #2's treatment plan after radiation therapy to the esophagus. […]

• No harm, potential for more than minimal, patternF880Feb 8, 2024

  Based on observations and interview, the facility failed to properly wear Personal Protective Equipment (PPE) to mitigate the spread of COVID-19 for three residents (#7, #63, #10) out of 10 residents positive for COVID-19 in the facility during a COVID-19 outbreak. Findings Included: A review of the facility's Special Droplet/Contact Precautions isolation sign revealed the following: Everyone Must: including visitors, doctors and staff Clean hands when entering and leaving room Wear face mask Wear eye protection (face shield or goggles) Gown and glove at door . A review of Resident #63's Physician order, dated 1/28/24, revealed Isolation-Droplet COVID + every shift for isolation for 10 days. […]

• No harm, potential for more than minimal, patternF585Jul 14, 2022

  Based on record review and interview, the facility failed to ensure prompt efforts were made to resolve grievances filed by the resident or resident representative for four ( Residents #1, #6, #7, #8) of five residents reviewed for resolution of grievances. Findings included: Record review of the facility grievance log for June 12, 2022, revealed Resident #1's representative filed a concern related to care and treatment. The log did not contain a documented resolution or date of notification of a resolution to the representative. On 07/14/2022 at 12:14 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated the grievance indicated the representative was unhappy with the staff and incontinent care. […]

• No harm, potential for more than minimal, isolatedF808Feb 18, 2026

  Based on observations, interviews, and record review the facility failed to follow the prescribed diet for two (Resident #2 and #6) of three residents sampled. Findings included: Durning an interview on 2/17/26 at 1:07 p.m. Resident #2's resident representative (RR) said on three different occasions when visiting staff were attempting to give Resident #2 fluids or food. RR stated Resident #2 was not to have anything by mouth. A review of Resident #2's medical record revealed an admission date of 12/9/25 and readmission on [DATE] with the following diagnosis to include but not limited to: malignant neoplasm of esophagus; dysphagia; and dementia. […]

• No harm, potential for more than minimal, isolatedF550Feb 8, 2024

  Based on observations, interviews, and record review, the facility failed to honor one resident's (#27) preference to take showers out of four residents sampled for choices Findings included: During an observation on 02/05/2024 at 10:00 a.m., Resident #27 was observed sitting in her wheelchair fully dressed. Resident #27 said she was very frustrated because she had a fall a couple of months of ago that has caused her to have to be put in a Hoyer lift. She stated she has not had a shower since the incident that happened 5 or 6 months ago. During an observation on 02/06/2024 at 12:00 p.m., Resident #27 was observed laying down in bed. Resident #27 restated she had not been able to have a shower since an incident she had 6 months ago. […]