The Inn at Freedom Village

A staff member used a loud, demeaning voice toward a resident and repeatedly told them to be quiet after being asked a question.

Poisonous materials, specifically Purell liquid soap, were left unlocked and accessible to residents in the Memory Care Unit.

The staff training plan lacked required details, including names, positions, duties, and scheduled training locations/times for the upcoming year.

A resident was found with a head injury after being struck with a lamp by another resident, indicating an incident of physical abuse/mistreatment.

A staff member failed to complete required orientation training regarding resident rights, emergency medical plans, and mandatory reporting within their first 40 working hours.

A staff member used excessive force and improper handling while transporting an agitated resident, causing the resident to fall out of their wheelchair.

A resident was neglected and not checked for incontinence or repositioned according to their three-hour care requirements.

A staff member involved in an incident was not suspended or placed on a plan of supervision.

An allegation of resident abuse was not reported to the local area agency on aging.

A resident did not receive required physical assistance with toileting and body repositioning as indicated in their support plan.

Staff persons A, B, and C did not have documented training in Resident Rights for the 2022 training year.

The resident-home contract for resident #1 was not signed by the resident.

The main entrance door to the home was inoperable and locked since 3/18/2023.

Resident 1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.

An uncovered, unattended trash can was found in the kitchen.

Improper medication administration/documentation related to restraints for Resident #1 and Resident #2.

Four bags of flour tortillas with an expiration date of 02/20/22 were found in the food pantry.

Resident #1 was found wearing a nightgown from the previous evening, indicating they did not receive required assistance with dressing.

The resident's support plan failed to document how the resident's identified need for dressing assistance would be met.

The medical evaluation for Resident #1 did not document the necessity for the resident to be served in the Secure Dementia Care Unit.

Staff failed to clean or sanitize the medication cart countertop before preparing and administering medication.

Poisonous materials, including mouthwash and toothpaste, were found unlocked and accessible in a resident's bathroom.

The small refrigerator and freezer in the dining area lacked thermometers.

An unlabeled and undated container of frozen mixed berries was found in the dining area refrigerator.

A prescribed medication (Cloraseptic Throat spray) for a resident was not present on the medication cart.