Manor Court of Freeport

In the surveyor’s words

From the most serious findings on record at Manor Court of Freeport, in the surveyor’s own words.

• Immediate jeopardy, isolatedF602Jun 23, 2021

  Based on observation, interview, and record review, the facility failed to prevent the diversion of residents' narcotic pain medication and the substitution with an unknown substance. This failure lead to a resident (R2) experiencing pain, with no narcotic relief available. This failure applies to 3 of 3 residents (R1, R2, R3) reviewed for misappropriation of resident property in the sample of 8. The Immediate Jeopardy began on 5/16/21 at 2:57 PM when V8, Registered Nurse notified V1, Administrator of inconsistencies regarding a [MEDICATION(S)] order for R1. The Immediate Jeopardy was identified on 5/27/21. V1 was notified of the Immediate Jeopardy on 6/22/21 at 4:10 PM. […]

• Immediate jeopardy, isolatedF755Jun 23, 2021

  Based on observation, interview, and record review the facility failed to have procedures to identify [MEDICATION(S)] that had been tampered with and failed to ensure residents did not receive [MEDICATION(S)] that had been tampered with. This failure also resulted in the facility not having access to liquid [MEDICATION(S)] for residents in pain. This failure applies to 3 of 3 residents (R1, R2, R3) reviewed for controlled substances in the sample of 8. The Immediate Jeopardy began on 5/16/21 at 2:57 PM when V8 Registered Nurse notified V1 Administrator of inconsistencies regarding a [MEDICATION(S)] order for R1. The Immediate Jeopardy was identified on 5/27/21. V1 was notified of the Immediate Jeopardy on 6/3/21 at 1:00 PM. […]

• Actual harm, isolatedF686Mar 19, 2026

  Based on interview and record review, the facility failed to perform weekly skin assessments, failed to identity a pressure ulcer prior to late stages for 1 resident, failed to obtain physician's orders for treatment of a pressure ulcer for 1 resident. This failure resulted in R3 obtaining a Stage 3 pressure ulcer that required surgical debridement and advanced to a Stage 4 pressure ulcer. These failures apply to 1 of 3 residents reviewed for pressure ulcers in the sample of 3.The findings include:R3's electronic face sheet, printed on 3/19/26, showed R3 has diagnoses including but not limited to dementia without behaviors, pain in right hip, stage 3 pressure ulcer to right hip, and depression.R3's facility assessment, dated 12/13/25, showed R3 has moderate cognitive impairment, requires… […]

• Actual harm, isolatedF689Aug 19, 2025

  Based on observation, interview, and record review, the facility failed to provide safe mobility for residents by not ensuring footrests were on wheelchairs when pushing residents for 4 of 6 residents (R1, R4, R5, & R6) reviewed for safety in the sample of 6. This failure resulted in R1 falling out of the wheelchair and sustaining a laceration that required 3 sutures to close.The findings include:1.R1's Face Sheet, dated 8/19/25, showed diagnoses including vascular dementia, moderate, with psychotic disturbance, encephalopathy, type 2 diabetes mellitus, nutritional anemia, atherosclerotic heart disease, hyperlipidemia, hypokalemia, hypothyroidism, vitamin D deficiency, anxiety disorder, depression, idiopathic gout, pain, overactive bladder, diarrhea, constipation, dysuria, and muscle… […]

• Actual harm, isolatedF760Jul 8, 2025

  Based on interview and record review, the facility failed to administer a resident's (R1) sodium tablets for 12 days following his admission to the facility. This failure resulted in R1 experiencing a critically low sodium level, confusion, hallucinations, and a 15 day hospital stay to correct his sodium levels. This applies to 1 of 3 residents reviewed for medications in the sample of 5. The findings include: R1's electronic face sheet printed on 7/8/25 showed R1 has diagnoses including but not limited to permanent atrial fibrillation, syndrome of inappropriate secretion of antidiuretic hormone (SIADH), chronic kidney disease, and malignant neoplasm of bladder. R1's census report showed R1 was admitted to the facility on [DATE], and discharged to a local hospital on 6/16/25. […]