The Inn at Freedom Village.

“Staff person A and B did not receive in-person fire safety training completed by a fire safety expert or by a staff person trained by a fire safety expert during training year 2025. This was a repeated violation from 05/29/2025.”

“Resident #1's glucometer was not calibrated to the correct time, resulting in inaccurate medication administration records. On 4/29/26, a reading at 6:08am was recorded as 7:20am. On 4/10/26, a reading of 153 mg/dl was recorded as 161 at a different time.”

“The medication administration training record for staff person A does not include the full completion date, trainer signature or date, student signature or date, or an indication if the student requalified or failed to requalify.”

“Resident 1's support plan did not contain special diet information and plan for the resident's need for chopped meats, which is required to be included in support plans.”

“Resident 1's Support Plan was not completed on the Department's current standardized form and was missing the elements of aggression needs, supervision needs, and long term and short term memory needs.”

“A staff member spoke to a resident in a loud, demeaning voice, telling them they asked too many questions and repeatedly instructing them to be quiet, violating the requirement that residents be treated with dignity and respect.”

“A resident was physically abused by another resident. Staff witnessed resident 2 being pulled out of bed and hit with a lamp by resident 1, resulting in a large skin tear and bleeding on resident 2's head. Resident 2 was transported to the emergency room for evaluation.”

“The home's staff training plan does not include the name, position, and duties of each direct care staff member, nor does it include the times and locations of the scheduled training for each staff member for the upcoming year.”

“Purell high-performance liquid soap with a manufacturer's label indicating "Please keep out of reach of children; please contact poison control if swallowed" was unlocked, unattended, and accessible in the kitchen and all bedrooms to all residents in the Memory Care Unit. Not all residents have been assessed as capable of recognizing and using poisons safely.”

“On 7/02/2024, at 9:25 am, there was a strong urine odor in the bathroom of bedroom 1125, indicating unsanitary conditions.”

“On 7/02/2024, at 9:18 am, there was a trail of ants coming from outside the building through the window to bedroom 1125, indicating evidence of insect infestation.”

“The home's written emergency procedures do not include the contact information for each resident's designated person.”

“A resident was mistreated when staff person forcefully removed the resident's hands from a bookshelf and abruptly pulled the wheelchair backward, causing the resident to fall to the floor. The resident was agitated, not properly seated in the wheelchair, and the staff member failed to ensure the resident's safety.”

“Staff person B completed their 40th scheduled work hour on 6/21/22 without completing required orientation training in resident rights, emergency medical plan, mandatory reporting of abuse and neglect under the Older Adult Protective Services Act, and reporting of reportable incidents and conditions.”

“Staff person A failed to use positive interventions and safe management techniques when resident 1 was agitated and resisting. The resident's support plan indicated the need for repeated verbal prompts, multiple approach attempts, and moving the resident to a quieter environment to decrease anxiety. Instead, staff forcefully removed the resident's hands and abruptly pulled the wheelchair backward.”