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 Inn At Freedom Village, The during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, dementia with behavioral disturbance, and a history of combative behavior during care did not have a care plan addressing dementia-related behaviors. During incontinence care, the resident became combative, grabbing and attempting to hit CNAs. One CNA placed a pillow over the resident’s arms and leaned on it to hold the arms down while continuing care, contrary to facility training and dementia care policy, which direct staff to use redirection, step away, and notify the nurse rather than using restraint-like measures. Another CNA was initially unsure whether to report the incident, delaying immediate notification to nursing staff.
A resident with Parkinsonism, anxiety disorder, and dementia had a hospital discharge order and facility physician order for clonazepam 0.5 mg PO q24h PRN for anxiety, but the drug was not available in the facility for several days after admission. During this time, CNAs and an RN documented the resident as agitated, hitting staff, combative with care, and smearing BM, while an RN noted there was an order for clonazepam but no prescription on file and contacted the pharmacy and physician. The contracted pharmacy later confirmed it did not receive an electronic prescription for clonazepam until several days after admission, and the medication was not delivered until the following day, despite facility policy requiring proper handling and documentation of controlled substances.
The facility failed to maintain safe operating conditions in two kitchen freezers, with significant ice build-up and condensation observed. Despite work orders being created, the issues persisted due to malfunctioning equipment and inadequate follow-up. The large walk-in freezer had a faulty door handle, contributing to ice accumulation, while the small walk-in freezer continued to have ice build-up despite maintenance efforts.
The facility failed to ensure accurate PASRR documentation for four residents, leading to deficiencies in identifying mental disorders or intellectual disabilities. Residents with diagnoses such as dementia, major depressive disorder, and bipolar disorder did not have their conditions accurately marked on PASRRs, and necessary Level II evaluations were not completed. Interviews revealed a lack of systematic processes to update PASRRs when new diagnoses or medications were added.
The facility failed to provide hand hygiene to residents in the dining room before meals, as observed during a lunch meal. Staff were seen assisting residents with seating and serving beverages but did not offer hand hygiene. Interviews with staff and residents revealed inconsistencies in the practice, with some staff unaware of the requirement and residents reporting infrequent hand hygiene offers. The Infection Preventionist acknowledged the expectation for hand hygiene but doubted its consistent implementation, despite the facility's policy emphasizing its importance.
The facility failed to protect residents' PHI by leaving nursing shift report forms unattended on medication carts in Wing A and Wing C. These forms, containing sensitive information, were observed on carts assigned to an RN and an LPN. Despite a policy requiring PHI to be safeguarded, the forms were left accessible, risking unauthorized access.
The facility failed to report elopement incidents involving two residents within the required timeframe. Both residents, with impaired cognition and requiring assistance with daily activities, were found in the parking lot. Initially not considered at risk for elopement, evaluations after the incidents determined they were at risk. The facility's policy mandates reporting such incidents, but the Nursing Home Administrator and Director of Nursing did not consider them reportable under abuse or neglect guidelines.
A resident with multiple diagnoses, including metabolic encephalopathy, was found with undated dressings on their feet, contrary to physician orders and facility protocols. Despite treatment records indicating care was provided, the dressings were not dated, as confirmed by staff interviews and facility policies.
A facility failed to maintain a medication error rate below 5%, with three errors observed out of 28 opportunities, resulting in a 10.71% error rate. Errors included incorrect dosage of Vitamin D25 administered by an RN and late administration of Ascorbic Acid and Metformin Hydrochloride to two residents. The facility's policy requires medications to be administered within one hour of the scheduled time and checked three times for accuracy, which was not adhered to.
A resident was found with unsecured medications on their bedside furniture, including Tylenol, nasal spray, and medicated powder, without a physician order for self-administration. The facility's policies on medication storage and self-administration were not followed, as revealed by staff interviews.
The facility failed to report abnormal lab results to the physician for two residents with chronic conditions. Despite receiving electronic reports of abnormal CBC and urinalysis results, the nursing staff did not review or communicate these findings to the physician, contrary to the facility's policy requiring direct communication for immediate notification.
Failure to Provide Competent Dementia Care and Appropriate Response to Combative Behavior
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were competent to provide appropriate care and services to a resident with dementia-related behaviors. The resident was admitted for short-term rehabilitation with diagnoses including Parkinsonism, anxiety disorder, and unspecified dementia with behavioral disturbance, and had a Minimum Data Set indicating moderate cognitive impairment. Review of the resident’s care plan showed no plan of care addressing behaviors related to dementia. A nursing progress note documented that the resident was combative with care and had smeared bowel movement on himself and the bed. During a night shift, a CNA (Staff H) attempted to provide incontinence care to the resident, who was covered in feces. The resident had previously grabbed Staff H’s wrist during care, so she requested assistance from another CNA (Staff G). While assisting, the resident grabbed Staff G’s hands and bent her fingers and then attempted to hit Staff H when they rolled him. In response, Staff H placed a pillow over the resident’s arms, leaned her right arm on the pillow to hold his arms down, and told him he was not going to be combative while she continued to clean him with her left hand. Staff H reported holding the resident in this manner for about 30 seconds until they were able to dress him and transfer him to a chair. Staff G reported being unsure about what she had witnessed and initially did not think she needed to report the event immediately, intending instead to ask the DON the next morning. Another CNA (Staff I) advised that the incident needed to be reported to a nurse, and the other CNA reported it. The nurse manager (Staff B) was notified and learned that Staff H had used a pillow to lean on the resident to prevent him from striking staff, which was not consistent with the facility’s training that CNAs should notify the nurse, step away, and reattempt care if redirection is unsuccessful when a resident is combative. Review of the facility’s dementia care policy indicated that restraints should not be used unless safety is an issue and only according to policy, with staff instructed to check with a supervisor before using restraints. The lack of a behavior-focused care plan and the use of a pillow to physically restrict the resident’s movement during care formed the basis of the deficiency.
Failure to Obtain and Provide Ordered Controlled Medication for Resident With Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that a prescribed controlled medication, clonazepam 0.5 mg, was available for a resident with Parkinsonism, anxiety disorder, and non-Alzheimer’s dementia with behavioral disturbance. The resident was admitted with a hospital discharge order for clonazepam 0.5 mg PO daily PRN for anxiety, and the facility’s physician orders dated 02/14/2026 reflected clonazepam 0.5 mg every 24 hours PRN for anxiousness related to anxiety disorder for 14 days. The resident’s MDS showed moderate cognitive impairment (BIMS score of 9) and active diagnoses of non-Alzheimer’s dementia and anxiety disorder. Despite these orders, the contracted pharmacy confirmed that no prescription for clonazepam was received before 02/20/2026, and the medication was not delivered to the facility until 02/21/2026. During this period without the ordered clonazepam available, documentation showed behavioral issues. A CNA note from 02/17/2026 at 02:00 a.m. described the resident as agitated and hitting staff, which triggered an alert on the facility’s EMR dashboard and was discussed in the morning clinical meeting. On 02/20/2026 at 03:33 a.m., an RN documented that the resident was combative with care, had smeared bowel movement on himself and the bed, and that although there was an order for clonazepam 0.5 mg PRN, there was “no script”; the pharmacy was called and the primary physician was made aware. A psychiatric ARNP visit on 02/20/2026 noted the resident was being followed for psychotropic medication management due to dementia with inappropriate behavior and resistance to ADL care at night, and the plan was to continue clonazepam 0.5 mg PO every 24 hours PRN for 14 days as currently prescribed. The facility’s own policy required compliance with all laws and requirements related to handling and documentation of controlled substances, yet the ordered controlled medication was not obtained and available for use until several days after admission.
Failure to Maintain Safe Operating Condition of Kitchen Freezers
Penalty
Summary
The facility failed to maintain food service equipment in a safe operating condition, specifically in two kitchen freezers. During a kitchen tour, significant ice build-up and condensation were observed in both the large walk-in freezer and the small walk-in freezer located inside the refrigerator. The large walk-in freezer had ice accumulation on the floor, ceiling, and racks, with icicles forming, while the small walk-in freezer had ice build-up on the blower unit and racks. The Director of Dining Services acknowledged that the door handle of the large walk-in freezer was malfunctioning, preventing it from sealing properly and contributing to the ice build-up. Despite work orders being created to address these issues, the problems persisted. The work orders for the small walk-in freezer were marked as completed, but the ice build-up continued, indicating that the underlying issues were not resolved. The Maintenance Director and the Nursing Home Administrator were involved in addressing the work orders, but the issues remained unresolved. The CDM later discovered that the vendor was waiting for parts to repair the large walk-in freezer, but there was a lack of timely follow-up and documentation regarding the delay. This lack of effective maintenance and follow-up led to the continued unsafe condition of the kitchen freezers.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Level I Preadmission Screening and Resident Review (PASRR) for four residents, leading to deficiencies in the identification and documentation of mental disorders or intellectual disabilities. Resident #1 was admitted with diagnoses including unspecified dementia, major depressive disorder, and panic disorder, yet the PASRR did not mark panic disorder or indicate the need for a Level II evaluation. The resident was on medications for anxiety and depression, and the care plan noted impaired cognitive function and the use of psychotropic medications. Resident #6 was admitted with diagnoses such as unspecified dementia, bipolar disorder, and major depressive disorder, but the PASRR left the section for mental illness blank. The resident was prescribed an antidepressant, and the care plan included interventions for depression. Similarly, Resident #30 had diagnoses including major depressive disorder and schizoaffective disorder, but the PASRR did not mark mental illness, and no Level II evaluation was completed. The resident had severe cognitive impairment and was on antipsychotic medication. Resident #24 was admitted with multiple diagnoses, including major depressive disorder and bipolar disorder, but the PASRR did not reflect these mental health conditions, nor was a Level II evaluation conducted. Interviews with facility staff revealed a lack of a systematic process to update PASRRs when new diagnoses or medications were added, contributing to the oversight. The facility's policy required screening for mental disorders and referral for Level II evaluation if indicated, but this was not consistently followed.
Failure to Provide Hand Hygiene Before Meals
Penalty
Summary
The facility failed to ensure that hand hygiene was offered to residents in the dining room prior to meals during an observation on July 15, 2024. During the lunch meal observation, it was noted that no hand hygiene was provided to the sixteen residents present in the dining room. Staff were observed assisting residents with seating and providing beverages and condiments, but did not offer any form of hand hygiene before serving the meal. Interviews with staff members revealed inconsistencies in the practice of offering hand hygiene, with some staff stating they provide hand hygiene in other contexts but not specifically before meals in the dining room. Interviews with residents confirmed the lack of consistent hand hygiene practices before meals. One resident reported that hand hygiene was only offered occasionally, and another resident stated that staff did not ask if they wanted to wash their hands before eating. The Infection Preventionist acknowledged the expectation for hand hygiene before meals and noted that staff had been educated on this practice, but expressed doubt that it was being consistently implemented. The facility's policy on hand hygiene, revised in August 2019, emphasizes its importance in preventing infection, yet the observations and interviews indicate a failure to adhere to this policy.
Failure to Protect Resident Health Information
Penalty
Summary
The facility failed to ensure the privacy of residents' personal health information (PHI) by leaving nursing shift report forms unattended on medication carts in the hallways of Wing A and Wing C. On multiple occasions, these forms were observed on top of medication carts assigned to a Registered Nurse (RN) and a Licensed Practical Nurse (LPN), containing sensitive information such as room numbers, scheduled skin checks, residents' names, mobility devices, blood sugar checks, and additional health details like diet, oxygen use, and urinary catheter information. Photographic evidence was obtained to document these observations. An interview with the Assistant Director of Nursing (ADON) revealed that nursing staff are expected to cover or turn over their nursing report forms to prevent the disclosure of PHI. The facility's policy, effective since August 1, 2020, outlines the need to safeguard PHI by ensuring documents are not easily accessible to unauthorized staff or visitors. Despite this policy, the observed incidents indicate a failure to adhere to these guidelines, resulting in the potential for unauthorized access to residents' confidential health information.
Failure to Timely Report Elopement Incidents
Penalty
Summary
The facility failed to report an alleged violation of abuse/neglect within the required timeframe concerning the elopement of two residents. Resident #43, who was admitted with diagnoses including atrial fibrillation, hypertension, and dementia, was found in the parking lot. The resident had a Brief Interview Status (BIMS) score of 00, indicating severely impaired cognition, and required assistance with activities of daily living. Initially, the resident was not considered at risk for elopement, but after the incident, an evaluation determined the resident was at risk. Similarly, Resident #281, with diagnoses including congestive heart failure, prostate cancer, and dementia, was also found in the parking lot. This resident had a BIMS score of 8, indicating moderately impaired cognition, and required substantial assistance with daily activities. Like Resident #43, Resident #281 was not initially considered at risk for elopement, but an evaluation after the incident determined the resident was at risk. The Nursing Home Administrator and Director of Nursing reviewed the elopement events and stated that elopements are not considered abuse or neglect, thus not reportable under Day 1 and Day 5 abuse and neglect reporting. However, the facility's policy requires all reports of resident abuse, neglect, exploitation, or theft to be reported to local, state, and federal agencies and thoroughly investigated. The facility submitted Adverse Incident Forms for both residents after the incidents, but not within the required timeframe.
Failure to Date Dressings for Resident
Penalty
Summary
The facility failed to provide nursing care according to standards by not properly dating skin care dressings for a resident. Resident #59, who was admitted with diagnoses including metabolic encephalopathy and rhabdomyolysis, was observed on two occasions with undated dressings on their feet. The resident reported that the dressings had not been changed for a couple of days, although the Treatment Administration Record indicated treatment was provided on specific dates. This discrepancy highlights a failure to adhere to the physician's orders for wound care, which required dressing changes on specific days. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that the facility's protocol required dressings to be dated and initialed after application. The facility's policies and procedures for wound care and dressings also mandated labeling with the date, time, and initials. Despite these guidelines, the dressings for Resident #59 were not dated, indicating a lapse in following established procedures for wound care management.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by observations, interviews, and record reviews. During the survey, 28 medication administration opportunities were observed, resulting in three errors involving three residents. This led to a medication error rate of 10.71%. Specifically, Staff E, RN, administered an incorrect dosage of Vitamin D25 (Cholecalciferol) to a resident, providing 1000 units instead of the ordered 3000 units. Additionally, two residents did not receive their scheduled medications on time, with one resident's Ascorbic Acid and another's Metformin Hydrochloride being administered late, despite the MAR being initialed as if they were given on time. The facility's policy on medication administration, revised in April 2019, requires medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time. The policy also mandates that the individual administering the medication checks the label three times to ensure the right resident, medication, dosage, and time. However, these protocols were not followed, as evidenced by the late administration of medications and incorrect dosage given, contributing to the high medication error rate observed during the survey.
Failure to Secure Medications for a Resident
Penalty
Summary
The facility failed to store medications safely and securely for one resident, as observed during a survey. Unsecured medications, including Tylenol, nasal spray, and medicated powder, were found on the bedside furniture of a resident who was cognitively intact. The resident reported taking Tylenol occasionally and informing the nurse when he did so. However, there was no physician order for self-administration of medications for this resident, nor was there an active care plan indicating that self-administration was permitted. Interviews with facility staff revealed a lack of adherence to the facility's policies regarding medication storage and self-administration. A Licensed Practical Nurse stated that medications found at the bedside should be taken and reported to a supervisor. The Director of Nursing indicated that medications should be stored in a lock box if found at the bedside and that an assessment should be conducted for self-administration. The facility's policies require that unauthorized medications at the bedside be returned to the nurse in charge and stored securely, which was not followed in this instance.
Failure to Report Laboratory Results to Physician
Penalty
Summary
The facility failed to ensure that laboratory results were reported to the provider and physician orders were followed up on for two residents. Resident #333, who was admitted with diagnoses including urinary tract infection, depression, and chronic kidney disease, had abnormal laboratory results for a CBC and urinalysis reported electronically to the facility. However, the staff did not review these lab reports, and the abnormal results were not communicated to the physician for review. Similarly, Resident #336, admitted with chronic kidney disease, Type 2 Diabetes Mellitus, and depression, also had abnormal CBC results reported electronically. These results were not reviewed by the nursing staff, nor were they reported to the physician. The Assistant Director of Nursing confirmed that the facility's process for reporting laboratory test results was not followed, as the nursing staff failed to notify the physician when the lab results were received. The facility's policy requires direct voice communication with the physician for results requiring immediate notification, which was not adhered to in these cases.
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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 Bradenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Casa Mora Rehabilitation And Extended Care | 0.3 mi | ★★★★★ | 8 | 3 |
| Heritage Park Health Center By Harborview | 0.4 mi | ★★★★★ | 6 | 0 |
| Surrey Place Healthcare And Rehabilitation | 0.5 mi | ★★★★★ | 0 | 0 |
| Aviata At Palma Sola Bay | 1.4 mi | ★★★★★ | 0 | 0 |
| Westminster Point Pleasant | 3.1 mi | ★★★★★ | 6 | 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.