Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Square Health Care Center during CMS and state inspections, most recent first.
A resident with esophageal cancer, PEG tube, severe cognitive impairment, and known post-radiation thick secretions developed increased mucus, phlegm, and coughing, leading to held tube feedings and new orders for IV fluids, diagnostics, and respiratory medications. The resident’s representative had previously discussed the need for possible suctioning with nursing, and was told suctioning was available. Later that night, staff documented the resident as stable at IV start, but shortly thereafter CNAs observed the resident unresponsive, with gurgling respirations and foam from the mouth, and reported that no suctioning was performed and oxygen was not effectively applied while the resident was still breathing. The assigned RN reported hearing crackles and noting very low O2 saturation, gave a nebulizer treatment, left the room to call 911 and obtain oxygen, did not bring the code cart with oxygen and suction because the resident was DNR, and was unable to get oxygen on the resident before death, contrary to the facility’s respiratory protocol that calls for airway check, crash cart, oxygen, and suction in respiratory distress.
Two residents did not receive diets as ordered by their physicians. One resident with esophageal cancer, dysphagia, and dementia had an NPO order but was repeatedly given or attempted to be given meal trays, as confirmed by grievances from the family and by facility staff. Another resident with ESRD on dialysis, diabetes with CKD, chronic hepatitis, and dementia had a 1000 ml/24 hr fluid restriction ordered, yet was observed with multiple cans of ginger ale and hot chocolate on the lunch tray, while CNAs stated the resident could have what he wanted with meals. There was no documentation of physician or family notification about this resident’s noncompliance with fluid restrictions, despite facility staff acknowledging that diets and restrictions should follow physician orders.
Failure to Provide Suctioning and Oxygen During Resident Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate respiratory treatment and airway management to a resident with known risk for thick secretions following esophageal radiation therapy. The resident had diagnoses including malignant neoplasm of the esophagus, gastrostomy status, adult failure to thrive, Alzheimer’s disease, and dysphagia, and was NPO with a PEG tube and a DNR order. The resident’s representative reported having multiple prior discussions with nursing staff about expected post-radiation side effects, specifically thick secretions that might require coughing or suctioning to clear the airway. On the evening in question, the representative was informed by nursing that the resident’s bolus tube feedings could not be administered because the resident was coughing and choking, and that the physician had ordered IV fluids, chest x-ray, abdominal x-ray, labs, and respiratory medications. The representative reiterated concerns about thick secretions and asked if suctioning was available; the nurse stated suctioning was available but had not been needed because the resident had been able to clear secretions. Progress notes show that earlier that evening the resident was documented as having increased mucus production, phlegm, and coughing, with PEG tube feeding held and STAT diagnostics and respiratory medications ordered. Later that night, the on-call practitioner instructed staff not to send the resident to the hospital, but to administer IV fluids and await lab and diagnostic results, and the resident representative agreed with this plan, with staff documenting that increased mucus was a common side effect of radiation and that the resident was being frequently monitored with the head of bed elevated. An IV of normal saline at 100 cc/hr was started around midnight, and documentation indicated the resident was stable, responsive, and alert at the time of IV placement. However, there is no documentation that suctioning or oxygen were initiated at any point despite ongoing concerns about increased mucus and cough. Around shortly before 1:00 a.m., staff accounts describe a significant change in the resident’s condition. A CNA reported that when she went to the room at the RN’s request, the resident was lying in bed unresponsive, breathing with sounds suggesting something stuck in his throat, and then making a gurgling sound, with foam coming from his mouth; she stated she did not see the RN or anyone else suction the resident or apply oxygen. Another CNA reported that when she entered the room, the resident had oxygen tubing on but it was not connected to an oxygen source, and that the RN never got oxygen hooked up while the resident was still breathing. The assigned RN stated he noted the resident with shortness of breath, heard crackling in the lungs but did not auscultate, obtained vital signs showing elevated blood pressure and very low oxygen saturation, administered a nebulizer treatment, attempted unsuccessfully to reach the physician, then left the room to call 911 and get oxygen, asking a CNA to watch the resident. He acknowledged that there was no oxygen or suction in the room, that he did not obtain the code cart containing oxygen and suction because the resident was DNR, and that he was unable to get oxygen on the resident before the resident took his last breaths. The respiratory therapist stated he had not been called, that staff were supposed to notify him when respiratory therapy might be needed, and that a resident with gurgling or suspected obstruction should have been suctioned and placed on oxygen, even if on hospice. The DON stated the RN’s documentation timeline did not align, that she would have expected the RN to stay with the resident, obtain the crash cart, suction the resident, and apply oxygen per the facility’s respiratory protocol, which directs staff in respiratory distress to check the airway, obtain the crash cart, place a non-rebreather mask with oxygen, suction as needed, call the physician, and call 911 if unable to stabilize the resident.
Failure to Follow Physician-Ordered NPO and Fluid-Restricted Diets
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets for two residents. One resident had diagnoses including malignant neoplasm of the esophagus, dysphagia, and dementia, with a BIMS score of 2 indicating significant cognitive impairment, and a physician order dated 12/9/25 for nothing by mouth (NPO). Despite this order, the resident’s representative reported three occasions when staff attempted to give the resident food or fluids, and the grievance log documented that the family filed grievances in December 2025 and January 2026 after the resident received meal trays on two separate occasions. The Social Service Director confirmed that the resident had received trays on both occasions, contrary to the NPO order. The second resident had diagnoses including ESRD with dependence on dialysis, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic hepatitis, and dementia, with a BIMS score of 5 indicating significant cognitive impairment, and was on a therapeutic diet with a physician order for a 1000 ml fluid restriction per 24 hours, divided between nursing and dietary. During observation, this resident was served a lunch tray with multiple cans of ginger ale and an additional cup of hot chocolate placed on the tray by a CNA, who stated the resident could have what he wanted and that he got enough, when asked about fluid restrictions. Another CNA stated that the computer system and tray ticket identify diet and fluid restrictions and that the resident could have what he liked with meals, just nothing in between. Record review showed no documentation of physician or family notification regarding the resident’s noncompliance with fluid restrictions. The RD and DON both stated that residents should receive diets as ordered by the physician and that notification should occur when there is noncompliance, but the RD acknowledged knowing of the resident’s noncompliance without having spoken with the dialysis center, physician, or family.
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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 Seminole
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Seminole | 1.3 mi | ★★★★★ | 6 | 0 |
| Wrights Healthcare And Rehabilitation Center | 2.2 mi | ★★★★★ | 8 | 0 |
| Palm Garden Of Largo | 2.4 mi | ★★★★★ | 2 | 0 |
| Aviata At Bryan Dairy | 2.6 mi | ★★★★★ | 4 | 4 |
| Gulf Shore Care Center | 3.4 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.