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
Based on facility documentation and staff interview it was determined the facility failed to follow physician
orders for bowel protocol for one of 16 residents reviewed. (Resident 15)
Residents Affected - Few
Findings Include:
Review of Resident 15's physician orders revealed an order dated August 31, 2022 for Milk of Magnesia
(laxative), give 30 cc (cubic centimeter or milliliters) by mouth as needed for constipation if no BM (Bowel
Movement) in 3 days: an order dated August 31, 2022 for Bisacodyl Suppository (laxative inserted rectally)
10mg (milligrams) as needed for constipation administer the next shift if no results from the Milk of
Magnesia; and an order dated August 31, 2022 for Fleets Naturals Cleansing Enema (rectal cleanser),
insert 1 unit rectally as needed for Constipation administer next shift if no results from Bisacodyl
Suppository.
Review of Resident 15's bowel continence report for May 2024 and June 2024 revealed the resident had no
bowel movement from May 29th, 2024 on evening shift until the day shift of June 4, 2024, totaling 5 days.
Review of Resident 15's Medication Administration Record (MAR) for the month of June 2024 revealed the
resident was administered Milk of Magnesia on June 2, 2024 at 1:58 p.m., review of the Bowel continence
reports revealed that was ineffective and was indicated as ineffective on the MAR. Further review of the
MAR revealed there was no Suppository administered as ordered due to the ineffectiveness of the Milk of
Magnesia.
Further review of Resident 15's bowel continence record for June 2024 revealed the resident did not have a
bowel movement from Evening shift on June 4, 2024 until day shift of June 13, 2024, a total of 9 days.
Review of Resident 15's MAR for June 2024 revealed the resident received Milk of Magnesia on June 8,
2024 at 8:10 a.m. that was ineffective. There was no Suppository administered for the ineffective Milk of
Magnesia on evening shift of June 8, 2024 as ordered and no other medications administered as ordered
until the resident had a bowel movement on June 13, 2024.
Further Review of Resident 15's MAR for June 2024 revealed the resident had a dose of Milk of Magnesia
administered on June 14 2024, at 12:49 p.m. which was not indicated due to the resident having a
documented bowel movement the day before.
Further review of Resident 15's Bowel record revealed the resident did not have a bowel movement from
evening shift on June 13 until day shift on June 23 a total of 10 days.
(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 3
Event ID:
396062
Printed: 05/15/2026
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
396062
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inn at Freedom Village,the
35 Freedom Boulevard
West Brandywine, PA 19320
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident 15's MAR for June 2024 revealed a dose of Milk of Magnesia as administered on June
19, 2023 at 2:17 a.m. and documented as effective but review of the bowel record revealed the resident did
not have a bowel movement on the night shift on June 14.
Further review of Resident 15's bowel record revealed the resident had no bowel movement from evening
shift of June 24, 2024 until the end of the month.
Review of Resident 15's MAR for June 2024 revealed there was a dose of Milk of Magnesia that was
administered on June 28, 2024 at 12:48 p.m. that was documented as ineffective and there was no
Suppository administer as ordered.
Interview with the Nursing Home Administrator and the Director of Nursing on September 13, 2024 at 10:00
a.m. confirmed that Resident 15's physician order for bowel regimen were not being followed as written.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396062
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
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
396062
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Inn at Freedom Village,the
35 Freedom Boulevard
West Brandywine, PA 19320
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, facility policy and procedure review, and staff interview it was determined the facility
failed to properly label and date vials of insulin for one of three med carts reviewed. (second floor)
Findings Include:
Review of facility policy and procedure titled Medication Labeling and Storage, dated 2001, revealed
Multi-dose vials that have been opened or accessed (e.g., needle puncture) are dated and discarded within
28 days unless the manufacturer specifies a shorter or longer date for the open vial.
Observation on September 11, 2024 at 9:20 a.m. of the medication cart on the second floor for the high
number rooms revealed there were four insulin pens that were opened and being used that were undated.
Interview with Nursing Employee E3 at the time of the above findings confirmed the four insulin pens were
opened and being used and should have been dated with the date they were opened.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
396062
If continuation sheet
Page 3 of 3
