Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interview and record review the facility failed to implement care the resident care plans for 2
of 25 (#18, #49) sampled residents related to posey application for #18, and documentation of meals for
#49.
Findings included:
1. Review of Resident #18's record revealed that he was admitted the facility on 10/1/19, and has
diagnoses that include Parkinson disease; Muscle weakness, Macular degeneration, wounds to the right
heel.
Review of the physician orders revealed a order for Place posey 6 inch spiral foot elevator to left ankle to
assist with prevention of further skin/joint integrity decline. Monitor frequently for skin integrity, circulation
and ROM (range of motion). When in bed & in wheelchair. May remove for transfers, the order was dated
10/22/2020.
Review of the care plan dated 9/4/20, with a revision date of 2/10/21 related to right heel and right lateral
foot with unavoidable Right 2nd toe, revealed that it included an intervention to Place Posey 6 inch spiral
foot elevator to left ankle to assist with prevention of further skin/joint integrity decline. Monitor frequently for
skin integrity, circulation and ROM. When out of bed
Observations 2/09/21 at 1:43 PM of the resident lying in bed revealed that there was no Posey present
while the resident was in bed.
Observations 2/10/21 at 8:35 AM revealed that Resident #18 was sitting up in bed with Staff G, Certified
Nursing Assistant (CNA) feeding him his morning meal. Continued observation of the resident revealed that
there was no Posey in place on the residents left ankle. Interview with Staff G at this time, she reported that
the resident is supposed to wear the soft boots all the time for his skin. She was unable to verbalize if the
resident uses any other devices. She reported that she was unsure because she floats and does not have a
set assignment.
Interview on 2/11/21 at 12:54 PM with the Director of Therapy revealed that the resident is on restorative
care for passive ROM, and has soft boots for wounds on the foot. She reported that the resident does have
a Posey for use on his left leg to prevent contractures and skin breakdown. She reported that at times the
resident is non-compliant and attempting to cross his legs, and at one point the resident was on hospice
and the residents wife would come for compassionate visits and she would take the posey off or put it on or
move it. The Therapy Director reported that the posey was ordered jointly from therapy and nursing to also
aid in wound healing. At this time this surveyor went to
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
105655
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105655
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/12/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inn at Freedom Village, The
6410 21st Ave W
Bradenton, FL 34209
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the resident's room to find the Posey with the Therapy Director present. The resident was not in his room
and the Posey could not be located in his room.
Observations on 2/11/21 at 1:06 PM of Resident #18 revealed him being wheeled to his room by Staff H,
CNA with Staff B, Licence Practical Nurse (LPN) and the Therapy Director present. The Posey was noted to
be on the residents left leg above the knee. Interview with Staff B, LPN at this time revealed that the
resident is to have the posey on at all times. The Therapy Director was present in the room and noted that
the Posey was on the residents left thigh above the knee, she was noted to adjust the posey by turning it
counter clockwise but leaving it above the knee, as she verbalized that the resident continued to try to cross
his legs.
Interview on 2/11/21 at 1:13 PM with Staff H, CNA revealed that the resident is to have on his Posey
everyday while in bed and in the wheelchair. She reported that she put it on this morning when she
provided care to the resident.
Interview on 2/11/21 at 1:15 PM with the DON and the Wound nurse, revealed that the resident has
vascular issues and likes to cross his legs. The Wound nurse reported that the posey is for the knees and
the ankles and should be on at all times. He reported that the Posey helps circulation and prevent legs from
crossing all the time and should be placed around the ankle.
Observations of Resident #18 on 2/11/21 at 1:20 PM with the Wound nurse present revealed that the
resident had the Posey placed above his left knee. Interview with the Wound nurse at this time revealed that
the Posey should be around the ankle, and that it should not be around his thigh.
2. Review of Resident #49's record revealed that this resident was admitted to the facility on [DATE] with a
re-admission date of 12/27/20, and has diagnoses that includes chronic kidney disease; Major Depressive
Disorder; Anxiety disorder; Malignant neoplasm of unspecified part of the Bronchus and other parts of the
face.
Observations of Resident #49 on 2/09/21 at 11:34 AM revealed the resident seated in his wheelchair in his
room in front of his over-bed table which had his morning meal on it, which consisted of 1 slice of French
toast, bacon, ham, syrup, milk, vanilla shake, Orange Juice, water. The resident was sitting with his head
hanging down and sleeping and none of his breakfast had been eaten. (photographic evidence obtained)
Observations on 2/09/21 at 11:39 AM Staff G, CNA noted to remove his meal tray out of the room. She was
not observed to encourage the resident to eat the meal and she did not offer him any alternative.
Observations on 2/09/21 at 12:30 PM revealed the residents mid-day meal tray was on his over-bed table,
which consisted of spaghetti, meat sauce, green beans, roll, Ice cream, milk, water, Juice, house shake.
The resident was noted to be asleep in his bed with his head covered with the sheets. Interview with Staff
G, CNA at this time revealed that the resident wanted to go back in the bed, but she was getting someone
to help her get him up now. She reported that he feeds himself.
Observations on 2/09/21 at 1:15 PM revealed that Resident #49 was still in bed with sheets over his head
and his mid-day meal was still on his over-bed table untouched.
Observations on 2/09/21 at 1:52 PM revealed that Resident #49's midday meal tray was still on his
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105655
If continuation sheet
Page 2 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105655
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/12/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inn at Freedom Village, The
6410 21st Ave W
Bradenton, FL 34209
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
over-bed table untouched, (photographic evidence obtained) while the resident was noted to still be in his
bed with covers over his head.
Observations of Resident #49 on 2/10/21 at 8:30 AM revealed that the resident was alert but hard of
hearing. He reported that his bandage is covering his skin cancer and that he has 2 cancers and that he is
a Bleeping mess It was noted that his morning meal tray was on his over bed table and consisted of eggs,
potatoes, toast, corn hash, Orange Juice, strawberry shake, coffee, milk, water. The resident was noted to
drink all fluids and asked for more fluids. He kept stating I want more to drink. An interview with the
resident's aide Staff G at this time revealed that she was unsure if the resident is offered anything else if he
does not eat his meal. She simply reported that he doesn't want anything, but was not observed to
encourage the resident to eat his meal or to offer an alternate. At this time she told the resident that she will
get him another tray.
Review of the care plan related to the resident being at a nutritional risk with an initiated date of 12/30/20
and a revision date of 2/9/21 revealed interventions that included Monitor meal intake with each meal
Review of the CNA documentation of percentage of meal eaten revealed that on 2/9/21 the resident ate
26%-50% of his morning and midday meals and refused his evening meal; On 2/10/21 the resident ate
26%-50% of his morning and midday meal and ate 0-25% of his evening meal; On 2/11/21 the resident at
51%-75% of his morning and midday meal and refused his evening meal.
Interview on 2/12/21 at 11:27 AM with the Registered Dietician (RD) and the Dietetic Technician,
Registered (DTR) revealed that the resident's weight was stable, that staff report that he does not eat well
but may drink at times. She reported that supplements are helping to maintain his weights and they will
continue to monitor.
Interview on 2/12/21 at 1:06 PM with the DTR revealed that the staff should be documenting % correctly so
that they can make appropriate interventions. She reported that the percentages documented do not reflect
the actual amounts the resident ate. She reported that she will in-service the staff on documenting %. She
confirmed that the % documented does not reflect the same as the actual amounts eaten.
3. Review of the facility policy titled Care Plans, Comprehensive Person-Centered with a revision date of
December 2016 revealed that A comprehensive, person-centered care plan that includes measurable
objectives and timetables to meet the reside's physical, psychosocial and functional needs is developed
and implemented for each resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105655
If continuation sheet
Page 3 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105655
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/12/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inn at Freedom Village, The
6410 21st Ave W
Bradenton, FL 34209
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interviews, and policy review, the facility did not appropriately secure medications in
four (A Wing North, A Wing South, Center Hall, and North Hall) of four medication carts.
Findings included:
On 02/11/21 at 12:35 p.m. an observation of the A Wing South medication cart included two (2) loose
tablets in the second drawer from the top of the medication cart. Staff A, Licensed Practical Nurse (LPN),
confirmed the presence of the unsecured white tablets.
On 02/11/21 at 10:31 a.m., an observation of the A Wing North medication cart included in the second
drawer ¼ of a green tablet, one (1) white tablet and ½ of a white tablet in loose, and in the
third drawer one loose white capsule. Staff B, (LPN) confirmed the presence of the unsecured tablets.
On 02/11/21 at 12:55 p.m. an observation of the medication cart on Center Hall included in the second
drawer one (1) white capsule, ¼ pink tablet and ¼ white tablet. Staff C, Registered Nurse,
(RN) confirmed the presence of the unsecured tablets.
On 02/11/21 at 01:15 p.m., an observation was conducted of the medication cart on the North Hall which
included 2 oval white tablets and ½ white loose tablets in the second drawer from the top of the
medication cart. The second drawer on the side of the medication cart, in the narcotic box included a
½ white loose tablet. Staff C, (RN) confirmed the presence of the unsecured tablets.
On 02/11/21 at 1:32 p.m., an interview with the Director of Nursing (DON) was conducted. The DON was
informed of observations made of four of four medication carts. The DON indicated there should not be
unsecured pills in any medication carts. She stated My expectation is that if the nurses find unsecured
medications, they should immediately destroy them, if they find unsecured narcotics in the narcotic box
then they must bring those loose pills to me and I will destroy them , and record it properly. (Photographic
Evidence Obtained.)
A review of the facility policy titled, Storage of Medications, with a revision date of April 2007 Page 33, read:
Policy Statement -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.
Policy Interpretation and Implementation:
1.
Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which
they are received.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105655
If continuation sheet
Page 4 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105655
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/12/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inn at Freedom Village, The
6410 21st Ave W
Bradenton, FL 34209
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0790
Provide routine and 24-hour emergency dental care for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation and interviews, the facility did not ensure that assistance was provided for dental
services to meet the needs of one resident (Resident #13) out of 25 sampled residents.
Residents Affected - Few
Findings included:
Record review of Resident #13 medical record revealed that she was admitted to the facility on [DATE].
Diagnoses included unspecified dementia without behavioral disturbances, major depressive order. Review
of the Brief Interview for Mental Status (BIMS) (3.0)-V1.1 dated 10/28/2020 Section D, titled Staff Interview
#8 Making Decisions Regarding Task of Daily Life revealed a score of 3, indicated that the resident's
cognition was severely impaired.
Observation on 02/09/21 at 12:26 p.m. revealed Resident # 13 being fed by staff. The food on her tray
appeared to be pureed or of soft consistency. Resident #13 had no teeth or dentures in place. During an
interview on 2/09/2021 at 12:27 p.m. with staff E Certified Nurse's Assistant (CNA) present at time of
observation. The CNA stated that Resident #13's dentures were loose, and they may have been sent out for
repairs.
During an interview with Staff F License Practical Nurse (LPN), unit manager on 2/11/2021 at 1:50 p.m.,
she stated that she needed to check to see what happened to Resident #13's denture. She proceeded to
Resident #13's room and entered the bathroom. Upon observation a denture was observed in a blue
denture cup. Upon closer observation, the denture appeared to be an upper denture. Staff F stated she was
not sure what has happened Resident #13's lower denture and confirmed that she should have been
wearing her denture.
An interview was conducted on 2/11/2021 at 2:00 p.m. with the Social Worker. She stated that she recently
assumed responsibility as the Social Worker beginning in December of 2020, and she is not aware of any
reports, services or follow up with the dentist related to Resident #13's denture.
During an interview with the Director of Nursing (DON) on 2/11/2021 at 2:15 p.m., the DON stated that she
is not aware of Resident #13 missing lower denture.
Review of care plan dated 8/21/2020 related to Resident #13 missing denture. The care plan revealed that
Resident #13 lower denture was missing, and that social service was aware.
A review of Dental Services Provider, Diagnosis and Recommended Treatment dated 11/19/20, revealed
that patient present for screening. Patient has upper denture and no lower denture Patient will not respond
if she wants a new set of dentures. No follow up needed.
During a follow up interview with the DON on 2/12/2021 at 8:20 a.m., the DON stated that the unit manager
usually follows up with recommendations for the residents. She stated that she will check to find out if there
were any follow up information available for Resident #13. The DON confirm that the facility should have
followed up with Resident #13's Responsible Party (RP) based on the Dental Service Provider
recommendation, due to Resident severely impaired cognition.
During an interview on 2/12/2021 at 9:15 a.m. with Resident #13's Responsible Party (RP) she stated that
she had brought Resident's dentures (upper and lower) to the facility upon her admission to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105655
If continuation sheet
Page 5 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105655
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/12/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inn at Freedom Village, The
6410 21st Ave W
Bradenton, FL 34209
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0790
Level of Harm - Minimal harm
or potential for actual harm
the facility. The RP stated that she noticed the lower denture missing either June or July of 2020 and has
been communicating with the Social Worker and the Charge Nurse about replacing the lower denture. She
was told how much it would cost to replace the denture and she agreed to pay the cost, but the facility has
not followed up with her. Resident #13's RP stated that she would love Resident to get her lower denture,
for her to be able to eat regular food (consistency).
Residents Affected - Few
Review physician order dated 12/15/2020 revealed Resident #13 diet as Controlled Carbohydrate Diet
(CCHO)Puree (Level1).
Review Nutrition Risk Review dated 10/26/2020, revealed diet: CCHO, Texture Modified and on 1/4/21
revealed diet as CCHO, pureed consistency.
Review progress note dated 11/19/2020, which stated that Residents #13's denture had been missing while
in Health Center, and she had refused follow up with the dentist on 10/21/2020 per social services.
Review social services notes dated 10/21/2020 stated that resident refused to see the dentist. Nurses note
dated 10/21/2020 also confirmed that resident refused to go to see the dentist. Record review did not reveal
that social service contacted Resident #13 RP due to her refusal to follow up with the dentist or to see the
dentist.
A review of Resident #13 Inventory of personal effects dated 4/23/2020, revealed that Resident #13 was
admitted with full upper and lower dentures.
Review of the Complaint/Grievance log dated 8/19/2020, revealed a report for Resident #13 lost lower
denture.
Record review of the facility policy and procedure titled, Dental Services, last revised December 2016
revealed:
#6. Social services representative will assist residents with appointments, transportation arrangements, and
for reimbursement of dental services under the state plan if eligible.
#9. Lost or damage dentures will be replaced at the resident's expense unless an employee or contractor of
the facility is responsible for accidentally or intentionally damaging dentures.
#10. If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the
referral is not made within three days, documentation will be provided regarding what is being done to
ensure that the resident is able to eat and drink adequately while awaiting dental services: and the reason
for the delay.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105655
If continuation sheet
Page 6 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105655
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/12/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inn at Freedom Village, The
6410 21st Ave W
Bradenton, FL 34209
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, interview and record review the facility failed to appropriately maintain the kitchen
equipment related to the range hood and 2 of 2 walk-in freezers.
Residents Affected - Few
Findings included:
Observations of the kitchen during the initial tour of 2/9/21 at 9:59 AM revealed that the range hood located
over the range unit was noted with dust and grease build-up. Observation of the purple service sticker
indicated that the unit was last cleaned by the vendor October 2020 and was due to be serviced again 1/21.
(Photographic evidence obtained) Interview with the Certified Dietary Manager (CDM) at this time revealed
that the vendor is scheduled to come and clean the hood now.
Observations on 2/11/21 at 9:15 AM during the Comprehensive tour of the kitchen revealed that the
Dessert walk-in freezer was noted to have built up ice around door and under the fans directly over food,
and icicles dripping and hanging from fans and located over food. (Photographic evidence obtained).
Continued inspection of the kitchen revealed that the Food walk-in freezer had ice build-up around door,
and ice formed and dripping on the ceiling over food. Interview with the CDM at this time revealed that she
is aware of the walk-in freezers having ice build-up and that she put in a work request via the tells system
and that someone came to look at it but they are waiting for a part to be ordered.
Review of the work history report for the walk-in freezers revealed that they were last inspected on 1/18/21.
No documentation of any concerns.
Review of the work request provided by the CDM revealed that in the 1st floor kitchen the freezer leak when
thawing during the day creating large amounts of ice in the freezer and attached to the units. Created
1/25/21 at 8:56 AM, assigned to Maintenance Manager at 9:06 AM (Set to Vendor Name Work Orders),
9:20 due date removed by maintenance manger. 1/27 Updated status 8:36 AM by maintenance Manager
(set closed ) priority was medium general maintenance.
Review of the work request provided by the Maintenance Manager revealed that the 1st floor kitchen The
freezer leak when thawing during the day creating large amounts of ice in the freezer and attached to the
units. created 1/25/8:56 AM, assigned to Maintenance Manager at 9:06 AM (Set to Vendor Name Work
Orders) , 9:20 due date removed by maintenance manger. 1/27 Updated status 8:36 AM by maintenance
Manager (set closed ) priority was medium general maintenance, with the addition of 2/11 Updated priority
9:42 AM set to High
Review of the Invoice from the vendor for heat and refrigeration invoice dated 1/26/21 indicating that they
serviced the healthcare 1st floor kitchen larger freezer, with labor that included Found that the drain pan
hanger had pulled out of unit, pulled up pan and put in new screw to hold pan, water now draining properly.
There was no documentation provided that would indicate that the ice build-up in the 2 walk-in freezers
were resolved.
Interview on 2/11/21 10:25 AM with the Maintenance Manager revealed that when there is an issue with
equipment in the kitchen the kitchen staff are to put in a work request via the work order system
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105655
If continuation sheet
Page 7 of 8
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105655
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/12/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inn at Freedom Village, The
6410 21st Ave W
Bradenton, FL 34209
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
and then the work will be completed or the vendor called to complete the work. Once the work is completed
it is documented on the work order system. He reported that the vendor for the walk-in freezer was here the
day after the kitchen put in a work request and that work was completed. He reported that he was unaware
that there was additional work as the additional work request was not put in until today.
Review of the facility policy titled Kitchen Equipment-Operation and Care with a revised date of August
2014 revealed To ensure that kitchen equipment be operated and maintained with the greatest care to
protect and prolong the useful life of the equipment.
Event ID:
Facility ID:
105655
If continuation sheet
Page 8 of 8
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F790 - Dental services
Provide routine and 24-hour emergency dental care for each resident.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the February 12, 2021 survey of INN AT FREEDOM VILLAGE, THE?
This was a inspection survey of INN AT FREEDOM VILLAGE, THE on February 12, 2021. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at INN AT FREEDOM VILLAGE, THE on February 12, 2021?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.