Freedom Square Health Care Center

Inspectors wroteBased 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. The RR stated the conversations included the side effects of the radiation therapy which included thick secretion that would need to be coughed up or suctioned to clear the air way. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow the prescribed diet for two (Resident #2 and #6) of three residents sampled.

Inspectors wroteBased 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. A review of Resident #7's Physician order, dated 1/30/24, revealed Special droplet/contact isolation every shift for COVID + 1/29 for 9 days. [...]

Inspectors wroteBased 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

Inspectors wroteBased on interviews and record review, the facility failed to accurately document for one resident (#107) on a discharge Minimum Data Set (MDS) out of five residents reviewed for transfer and discharge.

Inspectors wroteBased on interviews, observations, and record review the facility did not ensure pressure relieving interventions were ordered and implemented for one resident (#67) out of three sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure one resident (#41) out of thirty-four sampled residents, was provided with ordered psychiatric services; during two of three visits (11/30/2023 and 12/21/2023).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the prompt effort to resolve a grievance for one resident (#33) of two residents sampled for missing items. The facility did not ensure a hearing evaluation was completed and followed-up on according to the agreed upon grievance resolution, for Resident #33 related to a missing hearing aid.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders for the treatment and care of an indwelling catheter for one resident (#336) of five residents sampled were implemented within a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were available and provided for two residents (#11 and #188) of eight residents observed during medication administration.

Inspectors wroteBased on interview and record review the facility did not ensure pharmacist recommendations for one resident (#2) of five residents sampled were reviewed and implemented, or if rejected the facility failed to ensure a rationale was provided by the physician, within a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure behavior and side effect monitoring for psychotropic medication was conducted for one resident (#29) of five residents sampled.

Inspectors wroteBased on observations, interviews, and record reviews the facility did not ensure medications were secured for two residents (#47 and #48) out of 29 residents.

Inspectors wroteBased on observation, interview, record review, and policy review the facility did not ensure dental services for treatment were provided to one resident (#20) of twenty-five sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that three residents (#102, and #165), of 31 sampled residents, received care and treatment in accordance with recognized practice standards. Resident #102, who was recovering from hip surgery and at higher risk for blood clots, was not given his anticoagulant for 7 days because the medication was unavailable. Resident #165, who was recovering from an infection in his shoulder, did not have the surgical dressing on his shoulder changed for 21 days after his admission, due to the facility's failure to obtain orders for dressing changes. Resident #1 did not have her wound dressing changed every 3 days as ordered. Findings Included: 1. Review of the admission Record for Resident #102 revealed that he was admitted to the facility on [DATE], with diagnoses that included: [...]

Inspectors wroteBased on record review, interview, and policy review, the facility did not ensure the advanced directive wishes related to a do not resuscitate order (DNR) was accurately reflected in the medical record for two residents (#25 and #61) of 26 residents sampled for advanced directives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Schedule IV medications were stored in a permanently affixed compartment of the refrigerator in two (A-wing and C-wing) of two medication storage rooms, and the facility failed to ensure that medications were stored at the proper temperatures in one (C-wing) of two medication storage rooms. Findings Included: Observation on 1/23/20 at 10:20 a.m. with the Manager of Clinical Services/Staff N of the medication storage room on the A-Wing revealed a locked refrigerator with an attached freezer. The refrigerator was unlocked for inspection. Observation revealed an 8 ounce measuring cup, which contained a Ziploc bag with a dropper and a vial of Ativan (Lorazepam) 2 milligrams (mg)/milliliter (ml). The medication was labeled and belonged to a current resident. [...]

Inspectors wroteBased on observations, interviews, policy review and CDC guidelines, the facility did not ensure contact precautions were maintained during resident contact for one (#90) of two residents on contact precautions.