Inn at Freedom Village, The

In the surveyor’s words

From the most serious findings on record at Inn at Freedom Village, The, in the surveyor’s own words.

• Actual harm, isolatedF656Dec 1, 2022

  Based on record review and interviews, the facility failed to develop and implement a care plan to provide the level of assistance needed for one (#1) of three residents sampled for accidents. Resident #1 was assisted by one staff member with bed mobility during incontinence care resulting in a fall from the bed requiring a transfer to a higher level of care where she received treatment for her injuries of a nose fracture. Findings included: Review of Resident #1's admission record revealed an original admitted in 2017 and a most recent re-admitted [DATE] with diagnoses to include fracture of nasal bones, subsequent encounter for fracture with routine healing, fall from bed, muscle weakness, unspecified lack of coordination, and spinal stenosis of the lumbar region without neurogenic… […]

• No harm, potential for more than minimal, widespreadF908Jul 18, 2024

  Based on observations, interviews, and record review the facility failed to ensure food service equipment was maintained in a safe operating condition in two of two kitchen freezers. Findings included: On 7/15/24 at 9:44 a.m. a kitchen tour was conducted with the Director of Dining Services and the Assistant Director of Dining Services/Certified Dietary Manager (CDM). At 9:54 a.m. an observation of the large walk-in freezer revealed ice build-up on the floor upon walking in. Further observation of the large walk-in freezer revealed ice build-up and condensation throughout the freezer to include on top of racks and boxes of food items. The large walk-in freezer revealed icicles and ice build-up on the ceiling and floor. […]

• No harm, potential for more than minimal, patternF645Jul 18, 2024

  Based on interviews and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate for four Residents (#1, #6, #30, #24) out of 9 residents sampled for PASRR review. Findings included: 1. Review of the medical record for Resident #1 showed an admission to facility on 07/20/23 with diagnoses including unspecified dementia moderate with mood disturbance, dissociative and conversion disorder, major depressive disorder, and panic disorder. Review of the PASRR, dated 6/14/2023, showed on page two panic disorder not marked on section A. Mental Illness or suspected mental illness. Page 5 marked no diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation required. […]

• No harm, potential for more than minimal, patternF880Jul 18, 2024

  Based on observations, interviews, and record review, the facility failed to ensure hand hygiene was offered prior to meals to residents in the dining room during one (7/15/24) of one meal observations. Findings included: On 7/15/24 at 11:51 a.m. observations of the main dining room during the lunch meal revealed no hand hygiene was offered to residents prior to eating. There were sixteen resident in the dining room at the time of the observation. Residents were observed sitting down at their table of choice. Staff were observed assisting residents with positioning at the table. Staff were observed providing beverages and condiments to residents. At 12:29 p.m. staff started to provide each resident with their lunch meal. Observations of the main dining room from 11:51 a.m. to 12:40 p.m. […]

• No harm, potential for more than minimal, isolatedF744Mar 9, 2026

  Based on record reviews and interviews the facility failed to ensure staff were competent to provide direct care to a resident with behaviors due to dementia for one (Resident #1) out of three residents sampled.Findings include: Review of Resident #1's admission Record dated 03/09/2026 showed Resident #1 was admitted to the facility on [DATE] with diagnoses to include but not limited to Parkinsonism, anxiety disorder, unspecified dementia with other behavioral disturbance. Resident #1 was admitted to the facility for short term rehabilitation. Resident #1 was successfully discharged home according to the plan on 3/3/2026. Review of a Minimum Data Set, dated [DATE] showed a Brief Interview for Mental Status Score of 09 which indicated Moderate cognitive impairment. […]