Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Freedom Pointe Health Center during CMS and state inspections, most recent first.
A facility failed to provide and document wound care appropriately for three residents. One resident with NPWT had a dressing left in place when supplies were unavailable, with conflicting staff accounts and no clear provider notification; two other residents had dated dressings on arm wounds/skin tears without corresponding wound care orders or documented physician notification. Staff and the DON noted dressings should be dated and that wound findings should be communicated and ordered, but the records did not show that occurred.
Antibiotic stewardship failed when a resident with an E. coli UTI received Cipro even though the urine C&S showed ciprofloxacin resistance. The MAR documented the antibiotic was given for 7 days, while the DON, IP, and APRN described confusion over the culture review and antibiotic change process, and the facility policy required lab results and the resident’s condition to be communicated to the prescriber to determine whether therapy should be started, continued, modified, or discontinued.
Hot breakfast items were served at improper temperatures during meal service on the [NAME] Wing. The Assistant Dietary Director observed bacon, sausage patties, and hashbrowns on the steam table at 117 to 118 degrees F while breakfast was being served, and the Dietary Director acknowledged those temperatures were in the danger zone. Facility policy required hot foods to be held at 140 degrees F or higher.
Incomplete documentation of provider notification for medications given or held outside ordered parameters. Two residents had MAR entries showing carvedilol was held or not fully documented with vital signs, and oxycodone was administered for pain scores below the ordered PRN range, but the chart lacked progress note documentation that the provider was notified. The DON and staff stated provider notification should be documented, and the physician/APRN stated staff call to report held medications and pain medication use.
Hand Hygiene Not Performed During Wound Care: A wound care nurse failed to perform hand hygiene between wound care steps for a resident receiving NPWT to the left axilla. The nurse used two pairs of gloves, repeatedly removed only the top pair while leaving the original pair on, and continued care without washing hands while removing the dressing, cleansing the wound, applying the drape and foam, and connecting the tubing. The DON and IP stated hand hygiene should occur between steps and that gloves do not replace hand hygiene.
Two residents experienced significant weight loss due to the facility's failure to provide prescribed Magic Cup supplements. Despite physician orders, the supplements were not included on meal trays, contributing to a 9.85% and 7.56% weight loss for the residents. The facility had the supplements available, but staff did not ensure their delivery.
A resident with COPD and acute respiratory failure was observed receiving oxygen without a physician's order, contrary to facility policy. The resident's care plan indicated the need for oxygen use, but the Director of Nursing confirmed the absence of a current order, highlighting a failure in adhering to the required protocol for oxygen administration.
The facility failed to store medications properly, as observed in two residents' rooms. A resident had Magnesium Glycinate on their bedside table, which they brought from home, and another resident had Hydrogen Peroxide on their drawer without orders for it. The LPN and DON confirmed that medications should be locked, which was not followed.
The facility failed to ensure proper sanitation of equipment during food temperature checks. A cook used a towel to wipe a temperature probe between checking pureed foods without using alcohol wipes, contrary to facility policy. Both the Certified Dietary Manager and Registered Dietician confirmed the expectation to use alcohol wipes for sanitizing the probe.
The facility failed to ensure proper use of PPE and hand hygiene, leading to infection control deficiencies. An LPN did not wear a gown while administering medication to two residents under enhanced barrier precautions. Another LPN handled a fallen medication capsule without gloves and administered it to a resident. Additionally, an RN did not perform hand hygiene between glove changes during wound care, nor did they use a protective barrier on the bed.
The facility failed to document the administration of the influenza vaccine for two residents who had consented to receive it. Despite signed consents, there was no record of the vaccine being administered after the specified date. The Infection Preventionist confirmed the lack of documentation, and the DON emphasized the expectation for staff to document vaccine administration. The facility's policy requires the Infection Preventionist to oversee the annual influenza vaccine campaign.
Failure to Provide Ordered Wound Care and Proper Dressing Documentation
Penalty
Summary
The facility failed to ensure wound care and treatment were provided according to professional standards for three residents with skin conditions. For Resident #15, a wound gauze dressing to the left upper arm was observed without a date, and the resident stated the wound vac was not connected because staff realized they did not have suction supplies. The physician order required NPWT to the left axilla at 125 mmHg with dressing changes three times weekly and specific steps if the machine malfunctioned or supplies were unavailable. The TAR showed the order coded as "9" on 1/23/2026, and the progress note stated "Awaiting Supplies." Staff gave conflicting accounts about whether the dressing was changed, whether the vacuum remained connected, and whether the provider was notified. The DON later stated the dressing should have been dated and that the provider should have been contacted when staff were unable to change it. For Resident #4, a wound dressing to the left forearm was observed without a date. The resident stated the dressing had been in place for about a week after an event in the exercise room. Review of the physician orders did not show a wound care order for the left forearm, and the medical record did not contain documentation of an injury to that area. When the RN later observed the dressing, the corner was peeled back and a skin tear was seen underneath. The RN stated there were no wound care orders for the left arm, and the physician stated no one had informed him of a skin tear to the left forearm. For Resident #40, a dressing to the left forearm/left arm was observed dated 1/25/2026 with staff initials, but the physician orders did not contain a wound care order for that area. An LPN stated the dressing looked old and there were no dressing change orders. The DON stated dressings should be dated and that the usual process included a skin assessment, incident report, notification of the wound care nurse, entry of orders, and physician notification. The physician stated he had not been informed of a skin tear to the left arm and that there should be orders for wound care and treatment provided.
Antibiotic Given Despite Resistant Culture Result
Penalty
Summary
The facility failed to ensure that antibiotic therapy was administered based on urine culture and sensitivity results for one resident being treated for an E. coli UTI. The resident had a physician order for Cipro 500 mg by mouth twice daily for 7 days, and the MAR documented that Cipro was administered from 1/21/2026 through 1/27/2026. However, the urine culture report dated 1/21/2026 identified Escherichia coli and showed ciprofloxacin as resistant. The physician follow-up note stated that the resident was doing well and that the provider reviewed the urine culture and sensitivity, with a plan to discontinue Bactrim and change the resident to Cipro per the sensitivity report. During interviews, the DON stated the culture and sensitivity showed Cipro was resistant and that the expectation was to ensure prescribed antibiotics were correct. The Infection Preventionist stated she did not remember the resident’s culture and sensitivity and believed the provider had already reviewed it, while the APRN stated the preliminary results showed E. coli and that she started the resident on Cipro, later being notified that the antibiotic was resistant and had to be changed. The facility policy stated that when a culture and sensitivity is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine whether antibiotic therapy should be started, continued, modified, or discontinued.
Hot Breakfast Foods Held Below Required Temperature
Penalty
Summary
Hot food items were not maintained at proper temperatures during breakfast service on the [NAME] Wing. During observation at 7:32 AM, the Assistant Dietary Director was beginning to serve breakfast, and the bacon, sausage patties, and hashbrowns on the steam table were measured at 117 to 118 degrees Fahrenheit. The Assistant Dietary Director verified these temperatures during the observation. During interview, the Dietary Director stated that temperatures of 117 and 118 for hot food items are within the danger zone area. Review of the facility policy titled Temperatures and Safe Food Handling stated that hot foods must be held at 140 degrees Fahrenheit or more, and that failure to reheat to 165 degrees Fahrenheit or hold food at appropriate temperatures is not acceptable.
Incomplete documentation of provider notification for medications given or held outside ordered parameters
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for documentation of provider notification when physician orders were not followed as prescribed for two residents reviewed for medication management. For one resident, the physician ordered carvedilol 12.5 mg twice daily for hypertension, but the MAR showed multiple instances in January 2026 where the medication was held or coded outside parameters without corresponding documentation in the progress notes that the provider was notified. Entries included doses with missing blood pressure or pulse documentation and notes indicating the medication was held, while the record did not show provider notification for the missed or held administrations. Staff and the DON stated that when a medication is held, the provider should be notified and documented, and the physician stated staff call to notify when the medication is going to be held. For the second resident, the physician ordered oxycodone 5 mg every 8 hours as needed for acute pain rated 7-10, but the MAR documented multiple administrations when the recorded pain scores were below the ordered parameters, including pain levels of 6, 5, 2, and 4. The progress notes did not contain documentation that the provider was notified when oxycodone was administered outside the ordered pain range. Staff stated the medication was being given before wound care or because the resident preferred it, and the APRN stated staff call about the resident's pain medication and request from the patient. The facility policy required medications to be administered as prescribed and documentation to be complete and accurate in the medical record.
Hand Hygiene Not Performed During Wound Care
Penalty
Summary
The facility failed to prevent the possible spread of infection during wound care for a resident with a physician order for negative pressure wound therapy to the left axilla at 125 mmHg. During observation, the wound care nurse performed hand hygiene, donned a gown and two sets of gloves, and entered the resident’s room. The nurse placed wound care supplies on top of the resident’s cabinet without a barrier, cleaned the bedside table, discarded a water cup, placed a newspaper on the resident’s recliner, sanitized the table, and then placed the wound care supplies on the table. During the wound care procedure, the nurse repeatedly removed only the top pair of gloves while leaving the original pair on, did not perform hand hygiene, and put on another pair of gloves before continuing with each step of care. This occurred when removing the dressing, cleansing the wound, applying the drape and black foam, and placing the tubing and adhesive pad. The nurse later removed both sets of gloves, performed hand hygiene, exited the room, returned, performed hand hygiene again, donned two sets of gloves, connected the canister tubing, initiated the negative pressure pump, dated the dressing, and then removed both sets of gloves and performed hand hygiene. The nurse stated hand hygiene should have been performed when the gloves were removed. The DON stated staff should wash their hands in between each wound care step, and the Infection Preventionist stated staff should perform hand hygiene and remove both sets of gloves before putting on new gloves.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to provide nutritional supplements to two residents, leading to significant weight loss. Resident #12, who had a history of weight loss and was at risk due to a fair appetite and refusal of supplements, was observed without the prescribed Magic Cup supplement on her meal trays on multiple occasions. Despite having a physician's order for the Magic Cup twice daily to address her weight loss, the resident's weight decreased from 136 lbs to 122.6 lbs, a 9.85% loss. The Registered Dietician noted the resident's challenges with supplement intake and the importance of the Magic Cup in meeting her caloric needs. Similarly, Resident #14, who was also at risk for unintentional weight loss, did not receive the prescribed Magic Cup supplement on her meal trays. Her weight decreased from 127 lbs to 117.4 lbs, a 7.56% loss. The resident had a recent change in her supplement from Ensure to Magic Cup due to taste preferences, but the supplement was not provided as ordered. Interviews with the Certified Dietary Manager and the Director of Nursing revealed that the facility had the Magic Cups available, and nursing staff were responsible for ensuring they were included on meal trays.
Oxygen Administration Without Physician Order
Penalty
Summary
The facility failed to ensure that a resident received oxygen as per physician orders. During observations on two consecutive days, the resident was noted to be receiving oxygen at 2 liters per minute via nasal cannula. However, a review of the resident's physician orders revealed no order for oxygen administration. This discrepancy indicates that the resident was receiving oxygen without a documented physician's order, which is a requirement for all medications and interventions according to the facility's policy. The resident in question had a care plan indicating altered respiratory status due to COPD and acute respiratory failure with hypoxia, which included oxygen use. Despite this, the Director of Nursing confirmed that there was no current order for oxygen administration in the facility records. The facility's policy on oxygen administration clearly states the necessity of a physician's order to guide the rate of oxygen delivery, which was not adhered to in this case.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to accepted professional principles in one of its units. During an observation, a bottle of Magnesium Glycinate was found on the bedside table of a resident who stated that they brought it from home because the facility did not carry that type. This indicates that the medication was not stored in a locked compartment as required by the facility's policy. Additionally, another observation revealed a bottle of Hydrogen Peroxide on top of a resident's drawer, despite the resident not having orders for it. The LPN Unit Manager acknowledged that medications should not be at the bedside and confirmed that the resident did not have orders for Hydrogen Peroxide. The Director of Nursing also stated that resident medication should be locked in a lock box inside the resident's drawer, which was not adhered to in these instances.
Failure to Sanitize Temperature Probe in Food Preparation
Penalty
Summary
The facility failed to ensure that staff sanitized equipment while taking food temperatures in accordance with professional standards. During an observation, a cook used a towel sitting on the prep table to wipe the temperature probe between taking temperatures of pureed foods, including oatmeal, eggs, and waffles, without using alcohol wipes after testing the first pureed food. The cook confirmed this practice during an interview. The Certified Dietary Manager stated that alcohol wipes should be used to clean the temperature probe, and if another source is needed, a clean paper towel should be used. The Registered Dietician also expected the dietary staff to use alcohol wipes between foods when using the temperature probe. The facility's policy and procedure on food temperatures, last reviewed in January 2024, required washing, rinsing, and sanitizing a dial face, metal probe-type thermometer with an alcohol wipe and re-sanitizing the thermometer after each use.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure staff used appropriate personal protective equipment (PPE) while providing care to residents under enhanced barrier precautions. During observations, a Licensed Practical Nurse (LPN) entered the rooms of two residents, both of whom had enhanced barrier precaution signage, without donning a gown. The LPN administered intravenous medication to one resident and medication via a gastric tube to another without wearing the required gown, despite the facility's policy stating that gowns and gloves should be used during high-contact care activities. Additionally, the facility did not ensure proper hand hygiene during medication administration. An LPN was observed handling a medication capsule that fell onto the medication cart without wearing gloves and then administered it to a resident. This action was contrary to the facility's policy, which requires discarding contaminated medication and following infection control procedures, including hand hygiene. The facility also failed to adhere to infection control standards during wound care. A Registered Nurse (RN) did not perform hand hygiene between glove changes while providing wound care to a resident with pressure wounds. The RN also neglected to place a protective barrier on the bed before starting the procedure. These actions were inconsistent with the facility's policy, which mandates handwashing between procedures and the use of protective barriers to prevent contamination.
Failure to Document Influenza Vaccination for Two Residents
Penalty
Summary
The facility failed to ensure that the health records of two residents, identified as Residents #3 and #7, documented the administration of the influenza vaccine or noted any medical contraindications or refusals. Resident #3 was admitted with diagnoses including dementia, atrial fibrillation, insomnia, and chronic pain syndrome. The records showed a flu vaccine consent signed on November 6, 2023, but there was no documentation of the vaccine being administered after this date. Similarly, Resident #7, who was admitted with heart failure, atrial fibrillation, dementia, and chronic kidney disease, also had a flu vaccine consent signed on November 6, 2023, with no subsequent documentation of vaccine administration. During interviews, the Infection Preventionist confirmed that both residents had consented to the flu vaccine, but there was no documentation of the vaccine being administered. The Infection Preventionist noted that the previous Infection Preventionist was responsible for the administration, and she could not find any documentation of the vaccine being given. The Director of Nursing stated that it is expected for staff to obtain an order, administer the vaccine, and document it in the record once consent is signed. The facility's policy on influenza prevention and control, last reviewed in January 2024, states that the Infection Preventionist is responsible for organizing and overseeing the annual influenza vaccine campaign, ensuring all residents and staff are offered the vaccine before the influenza season begins.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near The Villages
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lady Lake Specialty Care Center And Rehab | 1.7 mi | ★★★★★ | 10 | 2 |
| Villages Healthcare And Rehabilitation Center, The | 3.1 mi | ★★★★★ | 10 | 0 |
| Chatham Glen Healthcare And Rehabilitation Center | 3.2 mi | ★★★★★ | 5 | 0 |
| Club Healthcare And Rehabilitation Center At The V | 3.4 mi | ★★★★★ | 0 | 0 |
| Buffalo Crossings Healthcare & Rehabilitation Cen | 4.2 mi | ★★★★★ | 0 | 0 |
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