Flagler Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Flagler Health and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Dec 4, 2025

  Based on a review of facility staffing information, the facility failed to ensure that a Registered Nurse (RN), other than the Director of Nursing, provided services for at least eight consecutive hours a day, seven days a week when the resident census exceeded sixty (60) for two (11/09/25 and 11/23/25) of 29 days reviewed.The findings include:A review of the staffing assignment sheets for November 9, 2025, failed to identify an RN on the schedule, listing only Licensed Practical Nurses (LPN) for the 12 nursing staff assigned to provide patient care on all three shifts (Day, Evening, Night). […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2025

  Based on observations and interviews with staff, the facility failed to label and date opened refrigerated food, maintain food preparation equipment in a clean and sanitary manner, and ensure canned goods intended for consumption were stored off the floor. Unsafe food storage and handling present the potential to affect all residents who consume foods prepared in the facility's kitchen. The findings include:During an initial kitchen tour with the Director of Dietary Services (DDS) on 12/01/2025 at 10:20 AM, the walk-in refrigerator was found to contain two steam table pans containing a thick brown substance resembling gravy. Each was covered with clear plastic wrap, but neither was labeled with a date that the gravy was opened and dished into the pans. […]

• No harm, potential for more than minimal, widespreadF812Dec 21, 2023

  Based on kitchen food service observations, staff interviews, facility document review and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The facility failed to ensure that the dietary staff practiced the proper procedures for hand hygiene, disposable glove use, food storage and proper sanitation practices in the kitchen. Hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. […]

• No harm, potential for more than minimal, widespreadF908Dec 21, 2023

  Based on kitchen food service observations, staff interviews, and facility document review, the facility failed to ensure that all mechanical equipment in the kitchen was maintained in a safe operating condition. This failure had the potential to impact any resident receiving food from the facility's kitchen. The findings include: During the first tour of the facility kitchen on 12/18/2023 at 10:12 AM the Certified Dietary Manager (CDM) participated in the tour. Dietary Aide F was observed operating the dish machine. The wash cycle temperature was 110 degrees Fahrenheit ('F). Three loads were observed and the temperature did not change. The chlorine bleach sanitizer level was tested and resulted in 100 parts per million (ppm). […]

• No harm, potential for more than minimal, patternF755Dec 4, 2025

  Based on observations, interviews, medical record review, and facility policy and procedure review, the facility failed to ensure accurate administration of time-sensitive medications, specifically insulin ordered to be administered before breakfast, for five (Residents #46, #120, #10, #119, and #108) of seven residents reviewed who had medications ordered to be administered prior to breakfast.The findings include:On December 3, 2025 at 5:40 a.m., Registered Nurse (RN) C was advised that her medication pass would be observed. RN C stated, Oh, I finished already. If I knew you were coming, I would have waited for you. […]