Inspection·May 19, 2022

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/17/22 at 3:40 p.m. an interview was conducted with Staff Member C, MDSC. She stated the creation of the care plan interventions with Hospice PRN is the responsibility of the Social Worker. She stated the computer system assigns her name when the care plan is opened. On 05/17/2022 at 4:00 p.m. an interview was conducted with the Social Worker. She confirmed the focus of the care plan should have been updated. Review of the facility Policy titled Goals and Objectives, Care Plans revision date April 2009 showed: -Policy Statement: Care Plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. -Policy and Interpretation and Implementation: 1. Care plan goals and objectives as the desired outcome for a specific resident problem. 5. Goals and objectives are reviewed and or revised a. When there had been a significant change in the resident's condition; b. When the desired outcome has not been achieved, d. At least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105655 If continuation sheet Page 2 of 4 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 05/19/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure care and services were provided to one (#74) out of twenty-five residents, as evidenced by not providing an antiemetic prior to transport to aid in the prevention of nausea and vomiting. Residents Affected - Few Findings Include: On 05/16/22 at 12:31 p.m. Resident #74 was observed lying in his bed and was receptive to an interview. He said he was just put in bed after he returned from a doctor's appointment and was not feeling well. He stated while at the eye doctor, I got sick. They usually give me something before I go out, but it didn't work this time. He went on to state I get car sick if I don't sit in the front seat. I have ever since I was a kid. He stated, I can't eat I am too nauseated from the car ride. The resident stated, once my eyes are fixed, I need to see an ear doctor to clean out my ears. Review of admission Record form revealed resident #74 has resided at the facility for two years and diagnoses information included chronic kidney disease, cerebral palsy, peptic ulcer disease and type 2 diabetes mellitus. Review of Nursing notes on 05/16/2022 did not reveal the resident had a change in condition related to nausea and vomiting. Review of Physician orders reflected an order for an antiemetic: Ondansetron HCL (Zofran) tablet 4 milligrams (mg) give 1 tablet by mouth every 6 hours as needed for nausea and vomiting dated 04/25/2022. Review of Medication Administration Record (MAR) for May 2022 revealed ondansetron (Zofran) 4mg tablet was administered on 05/02/2022 and on 05/08/2022. During an interview on 5/17/2022 at 9:50 a.m. Staff Member C Unit Manager (UM) confirmed she knew Resident #74 had got sick after transport to his appointment. She stated, He got his medication. On 05/17/2022 at 10:00 a.m. an interview was conducted with the Physician Assistant, who said he knew Resident #74. The Physician Assistant confirmed he was not aware the resident had nausea and vomiting when at his eye appointment on 05/16/2022. Review of medical record Physician Progress note dated 05/16/2022 read In order to schedule the patient we must first know if he can be transferred by stretcher and also medicated for his car sickness. Needs follow up Intraocular lens implant (IOL) appointment on 6/6/2022 12:50 p.m. and will need to be medicated for his car sickness. The Progress Note did not contain a Physicians signature. On 05/18/2022 at 12:22 p.m. an interview was conducted with the Staff C, UM, and Staff B. Licensed Practical Nurse (LPN). Staff BS confirmed she was the nurse assigned to Resident #74, and stated, did I forget to sign it out? Staff B was observed reviewing the resident's MAR. On 05/18/22 12:38 p.m. an interview was conducted with Staff A, Certified Nursing Assistant (CNA). She confirmed she knew Resident # 74, and said she escorted him to his appointment on 05/16/2022 at 10:00 a.m. She said she was unaware if he had received his medications before he left. Staff A stated after we arrived at the MD office we had to wait in the sitting room for a short period of time. When it was time, we entered the examination room the resident told me he felt sick. I grabbed the garbage can and he threw up two times. Staff A said he gets motion sick from the drive. And after we returned to the facility, I took him to his bedroom. He threw up again. Staff A stated they usually (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105655 If continuation sheet Page 3 of 4 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 05/19/2022 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 0684 give him something, so he doesn't get sick. But this time it didn't work. Level of Harm - Minimal harm or potential for actual harm On 05/19/22 10:00 a.m. an interview was conducted with Staff B, LPN. She confirmed at that time she had not provided the resident his Zofran prior to his appointment. She said, he was having pain after he was transferred into his wheelchair so, I gave him Tylenol. She then stated, he did not ask for the Zofran. Staff B confirmed she has provided the resident Zofran in the past prior transportation appointments, and confirmed she was aware transport makes the resident sick. Residents Affected - Few Further review of an administration note dated 04/20/2022 at 8:09 a.m. showed: -Zofran tablet 4 mg give 1 tablet every 6 hours as needed for nausea -Note Text: per resident request due to being transported to [hospital name] medical center. Review of an administration Note dated 05/02/2022 at 8:17 a.m. showed: -Created by staff B, Ondansetron HCL (Zofran) tablet 4 mg give 1 tablet by mouth every 6 hours as needed for nausea and vomiting -Note Text: to prevent car sickness appt at 9 am. The note did not reflect the resident had requested the medication. On 05/19/22 at 1:15 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated, it was a PRN medication, and he needs to ask for it. On 05/19/2022 at 2:40 p.m. the Director of Social Services provided a copy of Resident #74 Brief Interview for Mental Status (BIMS) dated 04/28/2022. She confirmed the BIMS score of 15 indicted no cognitive deficit. She stated, I had overheard the resident gets dizzy when he goes to appointments. Motion Sickness: What is motion sickness? If you've ever been sick to your stomach on a rocking boat or a bumpy airplane ride, you know the discomfort of motion sickness. It doesn't cause long-term problems, but it can make your life miserable, especially if you travel a lot. Children from 5 to [AGE] years old, women, and older adults get motion sickness more than others do. Motion sickness is sometimes called airsickness, seasickness, or carsickness. What causes it? You get motion sickness when one part of your balance-sensing system (your inner ear, eyes, and sensory nerves) senses that your body is moving, but the other parts don't. Accessed from https://joubinkhorsandmd.com/conditions/hw-view.php?DOCHWID=uf4437. on 05/19/2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105655 If continuation sheet Page 4 of 4