Inspection·April 13, 2023

N 000 INITIAL COMMENTS N 000 (Empty columns) An unannounced re-licensure and complaint investigation (complaint numbers 2022014844, 2023000345, 2023004401) was conducted at Freedom Pointe Health Center on through . All allegations in the complaints were not substantiated. The provider had deficiencies at the time of the visit.

N 054 59A-4.107(5), FAC Follow Physician Orders N 054 (Empty columns) All physician orders must be followed as prescribed, and if not followed, the reason must be recorded on the resident's medical record during that shift. This Statute or Rule is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure physician's orders for care services were followed for 2 of 2 sampled residents out of 10 residents receiving services (Resident #22 and #223). Photographic evidence obtained. Findings include: During an observation on Resident #222 was sitting in a bed side chair, at 11:36 AM observed on left upper arm. A transparent was over top of gauze securing the The was dated During an interview on at 11:36 AM Resident #222 stated that he came into the facility with the and the has not been changed since he was admitted. During an observation on at 1:18 PM Resident #222 a was on left upper arm with a transparent was over top of gauze STATE FORM 6809 OXUM11 C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

N 054 Continued From page 1 securing the . . . . The . . . . was dated

N 054 During an interview on B, Licensed Practical Nurse (LPN), confirmed that the . . . . was dated and should have been changed within 7 days. Review of the admission record for Resident #222 documented the resident was admitted on . . . . with diagnosis that included but not limited to . . . . of ankle and . . . . Review of physician orders for Resident #222, dated . . . . read: "Change and end caps every day shift every 7 days for . . . . [sic] control and as needed for soiled or not intact." During an interview on at 8:17 AM the Director of Nursing (DON) stated * changes for . . . . s are to be changed on admission if gauze is under the Tegaderm (clear . . . .). If no gauze is under the Tegaderm and we can see the site and there is no issue, then the . . . . on the . . . . is changed in 7 days." Review of the policy titled "Central . . . . Changes," last reviewed . . . . read "The purpose of this procedure is to prevent . . . . -related . . . . that are associated with contaminated, loosened, soiled, or wet . . . . General Guidelines. 4. After original insertion of CVAD ( Central . . . . ), the . . . . will consist of gauze and TSM (Transparent semi-permeable . . . .). This must be changed within 24 hours. 5. Change transparent semi-permeable . . . . at least every . . . . days and PRN (as needed when wet, soiled, or not intact). STATE FORM OXUM111 35961027 C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

N 054 Continued From page 2

N 054 6. If gauze is used, it must be changed every 2 days." Class III

N 094 SS=D 59A-4.112(5), FAC Drug Labeling

N 094 (5) Prescription drugs and biologicals used in the facility shall be labeled in accordance with currently accepted professional principles, Chapter 499, F.S. and Rules 64B16-28.108 and 64B16-28.502, F.A.C., as required by the Department of Health. This Statute or Rule is not met as evidenced by: Based on observation and interview the facility failed to ensure that all drugs and biologicals used in the facility were properly labeled in 2 of 4 medications carts. Photographic evidence obtained. Findings include: 1). During an observation on ______ at 2:52 PM of the west wing medication cart #2 with Staff B, Licensed Practical Nurse (LPN), two opened . Toujeo and . . . . , were not dated with date opened. During an interview on ______ at 2:55 PM, Staff B, LPN, confirmed the ______ in the west wing medication cart #2 were not dated with an open date or expiration date when removed from the refrigerator. Staff B stated, "When . . . . are removed from the refrigerator, we are supposed to date them with the open date and the expiration date." STATE FORM ndss OXUM111 C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159

N 094 Continued From page 3

N 094 During the observation on . . . at 3:18 PM of the west wing medication cart #2 with the east wing Nurse Manager, one was lying in the cart, opened with no resident's name on the pen and one Lispro . . . with no opened date labeled on the pen. During an interview on . . . at 3:18 PM the east wing Nurse manager confirmed there the . . . was opened with no resident's name on the pen and one Lispro . . . with no opened date labeled on the pen. During an interview on . . . at 3:22 PM, the East Wing Nurse Manager confirmed the . . . were not dated when opened and no expiration dates were entered on . . . She stated, "When the . . . are removed from the refrigerator the open date and the expiration date must be written on the . . . These . . . expire within 28 days, but some . . . vary on the expiration days after opening." Class III

N 201 400.022(1)(I), FS Right to Adequate and SS=D Appropriate Health Care

N 201 (I) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. STATE FORM OXUM111 C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX COMPLETE DATE

N 201 Continued From page 4 N 201 This Statute or Rule is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure adequate and appropriate health care services were provided for a (____) access device in accordance with professional standards of practice for 1 (Resident #222) of 7 residents reviewed. Photographic evidence obtained. Findings include: During an observation on ____ at 11:36 AM Resident #222 was sitting in a bed side chair. A transparent ____ observed on left upper arm. A transparent ____ was over top of gauze securing the ____ The ____ was dated During an interview on ____ at 11:36 AM Resident #222 stated that he came into the facility with the ____ and the ____ has not been changed since he was admitted. ____ During an observation on ____ at 1:18 PM Resident #222 a ____ was on left upper arm with a transparent ____ was over top of gauze securing the ____ The ____ was dated During an interview on ____ at 2:52 PM Staff B, Licensed Practical Nurse (LPN), confirmed that the ____ was dated ____ and should have been changed within 7 days. Review of the admission record for Resident #222 documented the resident was admitted on ____ with diagnosis that included but not limited to ____ of ankle and ____ Review of physician orders for Resident #222. 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 TAG BY FULL REGULATORY OR LSC TAG BE CROSS-REFERENCED TO THE DATE IDENTIFYING INFORMATION) (EACH CORRECTIVE ACTION SHOULD APPROPRIATE DEFICIENCY)

N 201 Continued From page 5 N 201 dated ...... read: "Change and end caps every day shift every 7 days for .... [sic] control and as needed for soiled or not intact". During an interview on at 8:17 AM the Director of Nursing (DON) stated " changes for 's are to be changed on admission if gauze is under the Tegaderm (clear ...). If no gauze is under the Tegaderm and we can see the site and there is no issue, then the ... on the is changed in 7 days." Review of the policy titled "Central .... Changes," last reviewed .... read "The purpose of this procedure is to prevent .... -related .... that are associated with contaminated, loosened, soiled, or wet .... General Guidelines. 4. After original insertion of CVAD ( Central ...), the .... will consist of gauze and TSM (Transparent semi-permeable ...). This must be changed within 24 hours. 5. Change transparent semi-permeable .... at least every ... days and PRN (as needed when wet, soiled, or not intact). 6. If gauze is used, it must be changed every 2 days." Class III STATE FORM SUMMARY OF DEFICIENCIES 106083 C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG (EACH SUMMARY MUST BE PRECEDED BY FULL ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 000 INITIAL COMMENTS

F 000 An unannounced recertification and complaint survey for complaint number 2022014844, 202300345, 2023004401 was conducted on through at Freedom Pointe Health Center. All allegations in the complaints were not substantiated. The facility was not in compliance with 42 CFR 483, Requirements for Long Term Care Facilities.

F 578 Request/Refuse/Dscntue Trmt;Formlite Adv Dir SS=E CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F 578 $483.10(c)(6) The right to request, refuse, and/or discontinue treatment, (x) to participate in or refuse to participate in experimental research, and to formulate an advance directive. $483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. $483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. PLAN OF CORRECTION AND PLAN OF DEFICIENCIES C ______ 04/13/2023 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX PREFIX TAG TAG DEFICIENCY) COMPLETION DATE

F 578 F 578 Continued From page 1 ( ) If an adult individual is ________ at the time of admission and is unable to receive information or ______ whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law. (v) The facility is not relieved of its ______ to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: Based on record review and interview the facility failed to ensure residents received information related to the right to formulate an advance directive upon admission for 8 (Resident #26, #58, #123, #173, #174, #222, #224, and #325) of 18 residents sampled for advance directives review. Findings include: Record review of Resident #26's admission record documented Resident #26 was admitted to the facility on included essential ______ with diagnoses that ______ and ______. Record review of Resident #26's Advance Directives Policy and Record on documented Resident #26 had not been provided information related to the right to formulate an advance directive until Record review of Resident #58's admission 106083 C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 ID PREFIX TAG PREFIX TAG DEFICIENCY) COMPLETION DATE

F 578 Continued From page 2

F 578 record documented Resident #58 was admitted to the facility on with diagnoses that included essential and Record review of Resident #58's Advance Directives Policy and Record on documented Resident #58 had not been provided information related to the right to formulate an advance directive until Record review of Resident #123's admission record documented Resident #123 was admitted to the facility on with diagnoses that included 's , essential , and Record review of Resident #123's Advance Directives Policy and Record on documented Resident #123 had not been provided information related to the right to formulate an advance directive until Record review of Resident #173's admission record documented Resident #173 was admitted to the facility on with diagnoses that included and essential Record review of Resident #173's Advance Directives Policy and Record on documented Resident #173 had not been provided information related to the right to formulate an advance directive until Record review of Resident #174's admission record documented Resident #174 was admitted C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 578 Continued From page 3 to the facility on ...... with diagnoses that included type 2 without complications and pruritus. Record review of Resident #174's Advance Directives Policy and Record on documented Resident #174 had not been provided information related to the right to formulate an advance directive until ......

F 578 Record review of Resident #222's admission record documented Resident #222 was admitted to the facility on ...... with diagnoses that included essential ......, Walden Strom ......, and hypo-osmolality and hyponatremia. Record review of Resident #222's Advance Directives Policy and Record on documented Resident #222 had not been provided information related to the right to formulate an advance directive until ...... Record review of Resident #224's admission record documented Resident #224 was admitted to the facility on ...... with diagnoses that included ...... of bone and cartilage, ...... bile duct ......, and essential ...... Record review of Resident #224's Advance Directives Policy and Record on documented Resident #224 had not been provided information related to the right to formulate an advance directive until ...... Record review of Resident #325's record documented Resident #325 was admitted to the facility on ...... with diagnoses that included ...... I need to make sure I capture all the text, including the narrative. Let's go step by step: First, the top header: Then the left section: 106083 Right section: C 04/13/2023 Then the provider name and address: FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 Next, the table headers: PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE Now the deficiency entries: First deficiency (F 578):

F 578 Continued From page 4 hypertensive crisis, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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PLAN OF DEFICIENCIES C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 684 Continued From page 5 review the facility failed to ensure care and services were provided for a ( ) access device in accordance with professional standards of practice for 1 (Resident #222) of 7 residents reviewed. Photographic evidence obtained. Findings include: During an observation on at 11:36 AM Resident #222 was sitting in a bed side chair, observed on left upper arm. A transparent was over top of gauze securing the . The was dated During an interview on at 11:36 AM Resident #222 stated that he came into the facility with the and has not been changed since he was admitted. During an observation on at 1:18 PM Resident #222 a was on left upper arm with a transparent . was over top of gauze securing the . The was dated During an interview on B, Licensed Practical Nurse (LPN), confirmed that the was dated and should have been changed within 7 days. Review of the admission record for Resident #222 documented the resident was admitted on with diagnosis that included but not limited to of ankle and Review of physician orders for Resident #222, dated , read: "Change and end caps every day shift every 7 days for STATE SURVEY AGENCY LIST OF DEFICIENCIES C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG DEFICIENCY) (X7) COMPLETION DATE

F 684 Continued From page 6 ... [sic] control and as needed for soiled or not intact. During an interview on at 8:17 AM the Director of Nursing (DON) stated * changes for *s are to be changed on admission if gauze is under the Tegaderm (clear .). If no gauze is under the Tegaderm and we can see the site and there is no issue, then the ... on the ... changed in 7 days." Review of the policy titled "Central ... Changes," last reviewed ... read "The purpose of this procedure is to prevent ... related ... that are associated with contaminated, loosened, soiled, or wet ... General Guidelines. 4. After original insertion of CVAD ( Central ... ), the ... will consist of gauze and TSM (Transparent semi-permeable ... ). This must be changed within 24 hours. 5. Change transparent semi-permeable ... at least every ... days and PRN (as needed when wet, soiled, or not intact). 6. If gauze is used, it must be changed every 2 days."

F 684

F 695 SS=D CFR(s): 483.25(i) , Care and Suctioning

F 695 $ 483.25(i) ... , care, including ... care and suctioning. The facility must ensure that a resident who needs ... care, including care and suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. 106083 C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 ID PREFIX TAG PREFIX TAG COMPLETION DATE DEFICIENCY)

F 695 Continued From page 7

F 695 THIS REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure , care services were provided for 2 of 2 sampled residents out of 10 residents receiving services (Resident #22 and #223). Photographic evidence obtained. Findings include: During an observation on Resident #223 was sitting in a bedside recliner at 10:19 AM. The .. tubing was hanging on the regulator on the wall and the tubing was not dated. During an interview on Resident #223 stated "I only use .. when I have .. issues and the .. will clear it up, the .. rate is 2 and I never change it. The tubing has not been changed since I've been here." During an observation on Resident #223's .. tubing was not dated. at 1:49 PM During an observation on Resident #223 was sitting in his bedside recliner at 8:37 AM lying over the bedside table. There was no water observed in the bottle for the humidifier. Review of the admission record for Resident #223 documented an admission date of with diagnosis that included but not limited to , .. and encounter for surgical aftercare following surgery on the system. C ______ 04/13/2023 106083 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 FREEDOM POINTE HEALTH CENTER PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 695 Continued From page 8

F 695 Review of physician orders for Resident #233 dated ........ read " : . . at 2 liters per low ... saturation." as needed for Review of physician orders for Resident #233 dated ........ read " ( . . ): Change .. tubing and date with securement bag ... Every night shift every Wed (Wednesday)." During an observation on ........ at 9:47 AM Resident #22 was sitting in a recliner beside her bed. Resident #22's ... tubing was not dated and the plastic bag hanging on the regulator was dated . During an interview on ........ at 9:47 AM Resident #22 stated "I use ... at night." During an observation on ........ at 1:34 PM Resident #22 was lying in bed. Resident #22's ... tubing was not dated. During an interview on ........ at 8:27 AM the Director of Nursing confirmed that Resident #22's ... tubing was not dated prior to her having the night shift go in and date the tubing the previous night. All tubing is supposed to be dated and changed on Wednesday nights, it was not changed and dated as ordered." Review of the physician orders for Resident #22 dated ........ read " : . . tubing (must be dated) every night shift every Wed [Wednesday] for ... control." Review of the facility policy title " .. Administration," last reviewed ........, read 106083 C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 ID PREFIX TAG PREFIX TAG COMPLETION DEFICIENCY) DATE

F 695 Continued From page 9

F 695 "Purpose. The purpose of this procedure is to provide guidelines for safe .. administration. Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for administration. Steps in the Procedure. 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as .. flows through."

F 756 Drug Regimen Review, Report Irregular, Act On

F 756 SS=D CFR(s): 483.45(c)(1)(2)(4)(5) $483.45(c) Drug Regimen Review. $483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. $483.45(c)(2) This review must include a review of the resident's medical chart. $483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity pharmacist identified. (iii) The attending physician must document in the PLAN OF CORRECTION C 106083 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 756 Continued From page 10 resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. $483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that includes, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on record review and interview the facility failed to ensure a drug regimen review recommendation from the pharmacist was acted upon for 1 resident (Resident #6) of 5 residents reviewed. Findings include: Review of the admission record for Resident #6 documented the resident was admitted to the facility on . . . . . with diagnosis that included but not limited to and abnormalities of gait and mobility. Review of physician orders for Resident #6 dated read: "Voltaren Gel 1 % ( . . . . . ) Apply to Bilat . . . . . , every 8 hours as needed (PRN) for . . . . . " Review of physician orders for Resident #6 dated read: " . . . . . Apply to Both . . . . . , every 12 hours as needed for . . . . . , Gel 1% as needed for . . . . . "

F 756 C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 756 Continued From page 11

F 756 Review of pharmacist consultation report dated read "Recommendation: Please update the direction for 1% gel to 'Apply 2 grams to every 8 hours as needed.' Physician Response: 1% gel Apply 1 gm to both every 12 hours prn for, ." Physician dated document ......... Review of pharmacist consultation report dated read "Recommendation: Please update the directions for 1% gel to 'Apply 2 grams to every 8 hours as needed. (Clarify dosing - have duplicate orders). Physician Response: I accept the recommendations, please implement as written." Physician dated document Review of pharmacist consultation report dated read "Recommendation: Please update the directions for 1% gel to 'Apply 2 grams to every 8 hours as needed. (Clarify dosing - have duplicate orders). Physician Response: I accept the recommendations, please implement as written." Physician dated document ......... Review of Resident #6's clinical records failed to document the facility acted upon the pharmacist recommendations. During an interview on at 1:44 PM, the Director of Nursing stated that the physician had agreed with the pharmacist's recommendation but the recommendations had not been acted upon. Review of policy titled "Interim Medication" C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE (X7)

F 756 Continued From page 12 Regimen Review ( , last reviewed , showed the policy read: "The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician / Prescriber to either accept and act upon the recommendations contained within the MRR ( Medication Regimen Review) or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 Facility should alert the Medical Director where MRRs are not addressed by the attending physician in a timely manner."

F 756

F 761 Label/Store Drugs and Biologicals SS=D CFR(s): 483.45(g)(h)(1)(2) $483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. $483.45(h) Storage of Drugs and Biologicals $483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. $483.45(h)(2) The facility must provide separately

F 761 PLAN OF DEFICIENCIES C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 DEFICIENCY)

F 761 Continued From page 13

F 761 locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug . . . Prevention and Control Act of 1976 and other drugs subject to . . . except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation and interview the facility failed to ensure that all drugs and biologicals used in the facility were properly labeled and stored in accordance with professional standards in 2 of 4 medications carts and two resident’s rooms, Resident # 222 and Resident #326. Photographic evidence obtained. Findings include: 1). During an observation on . . . at 2:52 PM of the west wing medication cart #2 with Staff B, Licensed Practical Nurse (LPN), two opened . . . and . . . were not dated with date opened. During an interview on . . . at 2:55 PM, Staff B, LPN, confirmed the . . . in the west wing medication cart #2 were not dated with an open date or expiration date when removed from the refrigerator. Staff B stated, “When . . . are removed from the refrigerator, we are supposed to date them with the open date and the expiration date.” During the observation on . . . at 3:18 PM of the west wing medication cart #2 with the east wing Nurse Manager, one . . . (2-99) lying in the cart, opened with no resident’s STATE SURVEY AGENCY NAME OF DEFICIENCIES C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 761 Continued From page 14 name on the pen and one Lispro . . . . with no opened date labeled on the pen. During an interview on . . . . at 3:18 PM the east wing Nurse Manager confirmed the . . . was opened with no resident's name on the pen and one Lispro . . . . with no opened date labeled on the pen. During an interview on . . . . at 3:22 PM, the East Wing Nurse Manager confirmed the . . . were not dated when opened and no expiration dates were entered on She stated, "When the . . . are removed from the refrigerator the open date and the expiration date must be written on the These . . . expire within 28 days, but some . . . vary on the expiration days after opening." 2). An observation on . . . . at 8:30 AM of Residents #222's room revealed a syringe of Normal . . . and a syringe of . . . lying on a bookshelf unsecured. An observation on . . . . at 7:51 AM of Residents #222's room revealed a syringe of lying on bookshelf unsecured. During an interview on . . . . at 8:05 AM, Staff C, LPN, confirmed the . . . syringe was lying on the bookshelf in Resident #222's room. Staff C confirmed that . . . syringe was at the bedside and stated, "this is to be locked up on the med cart, it should not be in here." During an interview on . . . . at 3:58 PM, the Director of Nursing (DON) stated her expectation was that no medications were to be PLAN OF CORRECTION C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 761 Continued From page 15 left at the bedside and that all ... when removed from the refrigerator were dated with the date and an expiration date when the was removed. 3). An observation on ... at 10:05 AM, Resident #326 was observed at bedside taking medications from a medication cup. Two pills remained in the med cup. During an interview on ... at 10:05 AM Resident #326 stated, "I'm not even sure what the meds are but one taste like iron or something." During an interview on ... at 10:52 AM Staff A, Registered Nurse (RN) stated that the nurse on the medication cart should prepare the medications for a resident, take it to the resident, administer the medications and then chart that the medications were given. Medications should not be left at bedside. When asked why Resident #326 had medication at bedside, Staff A stated, "Oh no, I guess I forgot to go when I went to get him something to drink." During an interview on ... at 11:15 AM the DON stated that the nurse on the medication cart should follow the protocol when passing medications. The DON confirmed that Staff A, RN was the nurse on the medication cart for Resident #326.

F 812 Food Procurement,Store/Prepare/Serve-Sanitary SS=E CFR(s): 483.60(i)(1)(2) $483.60(i) Food safety requirements. The facility must - C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 812 Continued From page 16 $483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. $483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen coolers and freezers, and failed to ensure equipment was cleaned and sanitized before use (Photographic evidence obtained). Findings include: During an observation at the time of initial walk-through tour of the kitchen on 9:16 AM with the Certified Dietary Manager (CDM), there were a large container with what appeared to be approximately 20 pieces of fresh raw chicken with red bloody fluids surrounding the bottom of the container in the walk-in cooler, a container of food that had a product with "Fresh Sliced Mushrooms" label by the shipper, with no received or expiration date, and a partial box of frozen raw beef patties located on the bottom C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 812 Continued From page 17 shelf with the lid open and the product exposed in the reach-in freezer. During an interview on at 9:45 AM, the CDM verified that the fresh raw chicken was stored in a container with pooling on the bottom of the container and should have been on an ice bed, that the fresh sliced mushrooms did not have a received, opened, a use by date, and that the raw frozen beef patties should have been stored in a closed container that did not expose the product to freezer . The CDM stated that the products should be labeled according to the policy, and all products should be closed or covered when stored. Review of the facility policy and procedure titled "Food Storage" revised on ______ and last reviewed on ______ reads, "Procedure: Raw Meat 4. Hamburger and fresh chicken should be cooked within one to two days of purchase. Fresh Chicken should be stored on ice to maintain an optimal temperature of 28 to 32 degrees F (Fahrenheit) ... Food Storage Frozen Meat/Poultry and Foods ... 3. Storage: Store items promptly to 0 degrees F or less or at a temperature maintains the food frozen. Foods should be stored in their original containers if designed for freezing. Foods to be frozen should be stored in airtight containers or wrapped in heavy-duty foil or special laminated papers. Label and date all food items." During an observation at the time of follow-up tour of the kitchen on ______ at 7:28 AM with the CDM, the can opener had a buildup of food residue and rust. The sanitation test strips being used had an expiration date of

F 812 C 04/13/2023 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE THE VILLAGES, FL 32159 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 812 Continued From page 18

F 812 During an interview on at 7:28 AM, the CDM confirmed the can opener had food residue and that the test strips currently being used were expired. Review of the facility policy and procedure titled "Can Opener", revised on and last reviewed on reads, "Sanitation of Equipment. Frequency: After each meal; more frequently if needed. 1. Remove shank to pot and pan sink, or to the dish machine area. 2. Scrub shank, paying attention to blade and moving parts. Use sanitizing solution and brush, or run through dish machine. 4. Air dry on clean surface." Review of the facility policy and procedure titled "Recording of Dish Machine Temperatures" revised on and last reviewed on reads, "6. The concentration of the sanitary solution during the rinse cycle is 50-100 ppm with sanitizer. This is used on low temperature dish machines. Assure that test strips are within the Use-By-date and not outdated."