Freelandville Community Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 1 of 3 dining observations. Butter packets were placed on top of food for the residents that were served and an ice scoop was observed in the container with ice used for resident drinks. (Kitchen)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's were treated with dignity and respect for 2 of 2 random observations and 1 of 1 resident reviewed for dignity. A resident totally dependent on staff was observed to wait 44 minutes and 19 minutes to use the bathroom. A resident in a Hoyer lift complained of pain when she was lifted but was not attended to at that time. (Resident 3, Resident 26)

Inspectors wroteBased on interview and record review, the facility failed to ensure physician notification of change for 2 of 2 residents reviewed for dialysis, and 1 of 4 residents reviewed for nutrition. The physician was not notified of a significant weight loss, signs/symptoms of atrial fibrillation (afib), and a resident that wanted to discontinue dialysis. (Resident 1, Resident 28, Resident 2)

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent and appropriately treat a urinary tract infection (UTI) for 1 of 1 resident reviewed for UTI. A resident was observed soiled from previous incontinence care, and an antibiotic was given prior to culture results that was resistant to the bacteria. (Resident 9)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ongoing communication between the dialysis center and the facility for 2 of 2 residents reviewed for dialysis. Clinical records lacked complete communication forms and documentation of dialysis access site being assessed after dialysis. (Resident 2, Resident 1)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Posted Nurse Staffing form contained the actual hours worked by the registered nurses, licensed practical nurses and certified nurse aides for 4 of 5 days reviewed for the survey. The Posted Nurse Staffing form did not contain the actual hours worked by the staff. (2/17/26, 2/18/26, 2/19/26, 2/20/26).

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate assistance was provided during a mechanical lift transfer and ensure staff used the equipment in accordance with facility policy for a resident who required extensive assistance of two staff and mechanical lift for transfers (Resident 137). The facility failed to ensure adequate supervision was provided in the bathroom for a cognitively impaired resident at risk of experiencing falls and failed to ensure a toilet seat was properly attached to the toilet for a resident (Resident 2). The facility failed to ensure new interventions were immediately implemented after a fall for Resident 137 and Resident 2 to prevent further falls for 2 of 3 residents reviewed for falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) Assessment was completed for 2 of 5 residents reviewed for unnecessary medications and 2 of 2 residents listed on the facility matrix as using restraints. The MDS indicated 2 residents used bed rails as restraints when they didn't, one resident received a hypoglycemic and was not coded, and one resident had a diagnosis of dementia that was not listed in the MDS. (Resident 19, Resident 29, Resident 15, Resident 8)

Inspectors wroteBased on interview and record review, the facility failed to ensure services of an RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 2 of the 7 days reviewed. (November 28, 2024, November 29, 2024)

Inspectors wroteBased on interview and record review, the facility failed to ensure detailed reporting of incidents for 2 of 3 facility incident reports reviewed. (Resident 2, Resident 137)

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan for 2 of 5 residents reviewed for Unnecessary Medications. Residents were administered a diuretic, insulin, anticoagulant, opioid, and antiplatelet medication and did not have a care plan related to the medication. (Resident 14, Resident 15)

Inspectors wroteBased on interview and record review, the facility failed to ensure services of an RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 4 of the days reviewed from the PBJ (Payroll Based Journal) Staffing Data Report during Quarter 3 of 2023 (April 1, 2023 through June 30, 2023).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 1 of 2 residents observed for urinary catheter care. The facility lacked preventative measures to keep legionella from forming in the water system for 3 of 3 halls. Gloves were not changed between dirty and clean tasks during catheter care. (Resident 16, Resident Halls[Wings] A, B, C) 1. During an observation on 11/16/23 at 10:42 A.M., urinary catheter care was performed by Certified Nurse Aide (CNA) 6 and CNA 8. CNA 6 failed to change gloves and sanitize or wash hands after catheter care was performed and Resident 16 was rolled to his side and CNA 6 used 2 washrags to wipe stool off of Resident 16. CNA 6 ran out of washrags and the Administrator brought in more washrags. At that time, CNA 6 washed hands and changed gloves. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents. The water temperature was above 120 degrees Fahrenheit in 1 of 3 halls. Items were sitting on bathroom floors uncovered, a call light cord was resting on a resident's bathroom floor, a privacy curtain was hanging off of the track, and a resident's wall was scuffed with paint chipping in 2 of 3 halls observed. (A Hall, C Hall)

Inspectors wroteBased on interview and record review, the facility failed to ensure Quarterly MDS (Minimum Data Set) Assessments were completed timely for 3 of 23 residents reviewed. (Resident 10, Resident 33, Resident 19)

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan for 1 of 1 residents reviewed for urinary catheters and 1 of 5 residents reviewed for unnecessary medications. A resident with a urinary catheter lacked a care plan related to the catheter, and a resident on an antidepressant lacked a care plan related to the antidepressant. (Resident 17, Resident 6) 1. On 11/14/23 at 1:04 P.M., Resident 17's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure and anemia. The most recent quarterly Minimum Data Set (MDS) Assessment, dated 11/14/23, indicated Resident 17 had an indwelling catheter. Current Physician Orders included, but were not limited to, change indwelling catheter every 28 days, dated 10/23/23. Resident 17's clinical record lacked a care plan related to the urinary catheter. During an interview on 11/15/23 at 1:30 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited mobility received appropriate services to maintain or improve mobility for 3 of 6 residents reviewed for restorative therapy. Residents did not receive intervention of restorative nursing services as indicated . (Resident 10, Resident 12, Resident 23)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents using psychotropic medications received gradual dose reductions (GDR) for continued use of the medications for 2 of 5 residents reviewed for unnecessary medications. Antidepressants and antianxiety medications were not reduced and a clinical contraindication for the reduction was not documented. (Resident 6, Resident 9)