The Inn at Freedom Village

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jan 30, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF838Feb 21, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF880Feb 21, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF888Mar 29, 2022

  Based on observation, interview, and record review, the facility failed to implement and operationalize their COVID-19 vaccination policy for staff, potentially affecting all facility residents, resulting in the facility not being aware of the vaccination and/or exemption status of contractual staff who are providing care and services to facility residents and the potential for the spread of illness and disease (COVID-19) among facility residents. Findings include: A review of the facility's Skilled Nursing Facility COVID-19 Vaccine-Employees/Staff policy, revised 2/7/22, revealed, Staff refers to any individuals that work or volunteer in the facility, regardless of clinical responsibility or resident contact. […]

• No harm, potential for more than minimal, widespreadF761Dec 10, 2021

  Based on observation, interview, and record review, the facility failed to properly label medications and maintain control of medications for 1 medication room and of 1 of 7 residents (Resident #2) observed during the medication pass observation, potentially affecting all facility residents, resulting in the potential for expired [MEDICATION(S)] Protein Derivative being administered, the potential for misappropriation, and the potential for Resident #2 not safely taking/not taking medications without the facility's knowledge, and the potential for residents receiving the wrong medications. Findings include: During an observation on [DATE] at 04:00 PM, the medication room was inspected with Licensed Practical Nurse (LPN) E. […]