Freedom Pointe Health Center
FREEDOM POINTE HEALTH CENTER in THE VILLAGES, FL — inspection on January 29, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an observation on 1/27/2026 at 3:55 PM Staff C, RN of Resident #4, the resident was lying in bed and to his left arm there was a dressing dated 1/26/2026.
Staff C peeled off the left corner of the dressing and there was a skin tear.
Staff C placed the dressing back on Resident #4's arm.
During an interview on 1/27/2026 at 4:00 PM Staff C, RN stated, I do not see any wound care orders for [Resident #4's name] left arm.
During an interview on 1/29/2026 at 12:52 PM Medical Doctor #2 stated, No one had brought to my attention [Resident #4's name] had a skin tear in his left forearm.3) During an observation on 1/26/2026 at 10:24 AM Resident #40 had a wound dressing to the left forearm dated 1/25/2026 with staff Initials.During an observation on 1/27/20256 at 10:40 AM Resident #40 had a wound dressing dated 1/25/2026 to the left arm. [Photographic evidence obtained]Review of Resident #40's physician orders did not contain an order for wound care for the resident's left arm.
During an interview on 1/27/2026 at 3:50 PM Staff D, LPN (Licensed Practical Nurse) stated, I did not pay attention to the date on the dressing. I did see that the dressing looked old. I checked; there are no dressing change orders.
During an interview on 1/27/2026 at 4:00 PM the Director of Nursing stated, Typically, we complete a risk and incident report.
The nurse would do a skin assessment, let the wound care nurse know and put in orders in the system; making sure the wound care nurse sees it to make sure that no other treatment is required.
The dressings should be dated.
The incident report has a check list and notifying the doctor is part of it and depending on the circumstances family is also notified.
During an interview on 1/29/2026 at 12:15 PM Medical Doctor #3 stated, I have not been informed of a skin tear to the left arm of [Resident #40's name].
There should be orders for wound care and treatment provided.
The nurse should write a progress note documenting the notification.
Review of the facility policy and procedure titled Care of Skin Tears-Abrasion and Minor Breaks with a last review date of 9/23/2025 read, Purpose: The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin.
Preparation. 1.
Obtain a physician's order as needed.
Document physician notification in medical record.
Steps in the Procedure:18.
Apply the ordered dressing and secure with tape or border dressing per order. (Note: Use non-allergenic tape as indicated.) Label with date and initials to top of dressing.
106083 01/29/2026
Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159
medication management.
Findings include:Review of Resident #61's physician order dated 1/21/2026
two times a day for E.
Coli UTI [Escherichia coli urinary tract infection] for 7 Days.Review of Resident #61's Medication Administration Record (MAR) for the month of January 2026 documented Cirpo 500 mg was administered from 1/21/2026 to 1/27/2026.Review of Resident #61's Urine Culture [a lab test that will identify the bacteria causing the infection] with a reported date of 1/21/2026 read, Results: Escherichia coli (Isolate 1).
Sensitivity Analysis.
Ciprofloxacin R [Resistant/ineffective].Review of Resident #61's physician follow up note dated 1/21/2026 read, Patient observed ambulating with physical therapy and doing well.
Reviewed urine culture and sensitivity.
Will have to discontinue Bactrim and change patient to cipro per sensitivity report.
Patient otherwise doing well.
During an interview on 1/28/2026 at 7:56 PM the Director of Nursing stated, I reviewed the culture and sensitivity and Cipro was resistant.
There was a note in the system that stated the antibiotic was changed to cipro due to the sensitivity.
Normally the results will come in and the Infection Preventionist will review the antibiotic and the sensitivity.
The expectation and normal process is to make sure that the antibiotics prescribed are correct.
During an interview on 1/28/2026 at 3:54 PM the Infection Preventionist stated, I don't remember that one [Resident #61's culture and sensitivity].
When I looked in the antibiotic time out it was the same day that the provider had changed it [the antibiotic] to cipro and I thought she had looked at it [the culture and sensitivity]. I understand now that I am to look at the culture to see if the antibiotic the provider changes it to is susceptible or not and notify the provider.
During an interview on 1/29/2026 at 11:41 AM APRN #2 stated, The preliminary results showed E.
Coli and I started her on Cipro. I have been notified that the antibiotic was resistive and had to be changed.
Review of the facility policy and procedure titled Antibiotic Stewardship with a last review date of 9/23/2025 read, Policy Statement.
Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program.
Policy Interpretation and Implementation: 11.
When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.
106083 01/29/2026
Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159
During an interview on 01/27/26 at approximately 7:33 AM the Assistant Dietary Director verified the temperatures of the bacon, sausage patties, and hashbrowns.
During an interview on 1/27/26 at approximately 8:00 AM the Dietary Director stated, The temperatures of 117 and 118 for hot food items are within the danger zone area.
Review of the policy and procedure titled, Temperatures and Safe Food Handling last reviewed on 09/23/26 read, Objective: Participants will be able to understand the importance of proper temperatures and food handling procedures when handling food for residents. 2. e.
Failure to reheat to 165 F or hold food at appropriate temperatures-cold food less than or equal to 41 F and hot foods more than or equal to 140 F.
106083 01/29/2026
Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159
Policy Statement: Medications are administered in a safe and timely manner, and as prescribed.
Charting and Documentation with a last review date of 9/23/2025 read, Policy Statement: All services
physical, functional or psychosocial condition, shall be documented in the resident's medical record.
The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
Policy Interpretation and Implementation. 3.
Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
106083 01/29/2026
Freedom Pointe Health Center 1460 El Camino Real Drive The Villages, FL 32159
reviewed for skin conditions.Findings include: Review of Resident #15's physician order dated
125 millimeters of mercury] pressure.
Remove dressing, cleanse wound with Dakins, Apply skin prep to peri-wound area.
Apply drape to peri-wound area.
Fill wound space with black foam, Cover with drape. Do not apply foam directly to skin without drape barrier.
Change dressing 3x [times] weekly. every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] AND as needed for compromised drg [dressing] seal.During an observation on 1/29/2026 at 11:45 AM the Wound Care Nurse performed hand hygiene, don a gown and two sets of gloves.
The Wound Care Nurse entered Resident #15's room and placed the wound care supplies on top of Resident #15's cabinet without placing a barrier underneath.
The Wound Care Nurse proceeded to clean Resident #15's bedside table, throwing away a water cup in the garbage, placing a newspaper on top of the resident's recliner, sanitized the bedside table, and placed the wound care supplies on the table.
The Wound Care Nurse removed the top pair of gloves leaving the first original pair of gloves on, did not perform hand hygiene, put a new pair of gloves on, on top of the first original gloves.
The Wound Care nurse removed the dressing from Resident #15's left arm, removed the top pair of gloves leaving the first original gloves on, did not perform hand hygiene, and put another pair of gloves on.
The Wound Care Nurse cleansed the wound, pat dried the wound, removed the top pair gloves leaving the original pair of gloves on, did not perform hand hygiene, and put another pair of gloves on.
The Wound Care Nurse applied a drape to the peri wound area, filled the wound with a black foam covering with a transparent drape, removed the top pair of gloves leaving the original pair on, did not perform hand hygiene, put a new set of gloves on, cut a hole in the barrier, and placed tubing with an adhesive pad over the wound.
The wound care nurse proceeded to look for a new disposable canister for the wound vacuum system.
One was not located in the resident's room.
The Wound Care Nurse removed both sets of gloves, performed hand hygiene, and exited the room.
The Wound Care Nurse returned to the room, performed hand hygiene, put two sets of gloves on, connected the canister tubing, and initiated the negative pressure on the pump for the wound vacuum as ordered.
The wound care nurse dated the wound dressing, removed both sets of gloves, and performed hand hygiene.
During an interview on 1/29/2026 at 12:15 PM the Wound Care Nurse stated, I should have performed hand hygiene when I took my gloves off.
During an interview on 1/28/2026 at 1:00 PM the Director of Nursing stated, Staff should wash their hands in between each wound care step.
The staff should take their gloves off and wash their hands and put a new pair of gloves on.
During an interview on 1/28/2026 at 3:54 PM the Infection Preventionists stated, I would expect the staff to perform hand hygiene. I don't know why they are putting two sets of gloves on.
They would need to remove both sets of gloves and put new gloves back on after washing their hands.
Review of the facility policy and procedure titled Handwashing/Hand Hygiene with a last review date of 9/23/2025 read, 9.
The use of gloves does not replace hand washing/hand hygiene.
Review of the facility policy and procedure titled Negative Pressure Wound Therapy with a last review date of 9/23/2025 read, Steps in the procedure: 1.
Identify and size the wound to be treated. 2.
Wash hands and apply gloves. 3 Clean wound according to facility protocol, or as ordered. 4.
Remove gloves. 5.
Wash Hands and apply clean gloves. 6.
Cut sponge dressing to size.